What is it?
On March 6, 2020, CMS finalized the Interoperability and Patient Access rule, building upon existing legislation to push for greater data exchange across the health care system. The regulation requires payers participating CHIP, Medicaid, and Medicare as well as plans on federal exchanges to make personal clinical and claims data accessible to members upon request. Affected payers must facilitate this data exchange by building application programming interfaces (APIs), or data infrastructures that allow third parties to connect to payers’ internal databases. Once health plans have implemented their APIs, third-party apps can request and retrieve health information on behalf of members.
Payers are required to build two separate APIs: a Patient Access API to house their personalized patient data, and a Provider Directory API to maintain an up-to-date list of in-network providers. While this rule doesn't require payers to build an API for the exchange of data from payer to payer, CMS included this requirement in their proposed Interoperability and Prior Authorization Rule, which has been temporarily withdrawn after being finalized earlier this year. While the compliance deadline for the Patient Access and Provider Directory APIs is July 1, 2021, the deadline for payers enabling payer-to-payer data exchange is July 1, 2022.
In addition to mandating that health plans build APIs, CMS published Fast Healthcare Interoperability Resources (FHIR), a set of standards that health data housed in APIs must meet. These guidelines offer a standardized format for health information so payers can integrate disparate data systems and create a single, longitudinal record for every member.