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FHIR Blog Series | Part 6 of 8: CMS Interoperability & Patient Access Rule - Payer to Payer Data Exchange


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FHIR Blog Series | Part 6 of 8

CMS Interoperability & Patient Access Rule – Payer to Payer Data Exchange

Shobhit Saran, AVP, Health Plans & Gati Patel, Healthcare Business Analyst, FAST+ Solution

September 25, 2020

In Part 5, we addressed the importance of a FHIR data repository to aggregate and normalize data from multiple sources into the FHIR standard. Part 6 of the series, emphasizes on the need of a tool which will ease the exchange of data when members switch health plans.

Current payer systems do not allow members to carry their data with them when they move between health plans or transition into Medicare. This often results in fragmented member data getting stored across various siloed systems, making it difficult for payers to obtain a holistic view of members health.

To overcome this challenge, CMS has included a policy in the Interoperability and Patient Access rule of “Payer-to-Payer Data Exchange”. This policy is applicable to all Medicare, Medicaid, and CHIP payers. According to the new policy which will come in effect from 1st January 2022, if a member moves from one payer to another the current payer will need to share that member’s health data to its new payer. It is crucial that payers share this data as a single file on behalf of the member. This will help obtain member’s health data while they switch between health plans. With this new policy, payers will be in an unique position to provide members with a comprehensive picture of their health, and make enhancements to existing data infrastructure essential.

Under the “Payer-to-Payer data exchange” policy, current payers are required to send member clinical data as per United States Core Data for Interoperability (USCDI) version-1 standard with new payers. Payers are liable to share this data till 5 years post the end of a member’s coverage or disenrollment. Payers are at the receiving end of this need to store member information in USCDI format in their data systems to ensure uniformity of the data.

In the Interoperability & Patient Access rule, CMS has finalized certain API standards for “Payer-to-Payer Data Exchange”. Payers need to build and maintain a standard-based FHIR API (as per FHIR Version 4.0.1) with necessary authentication and authorization mechanism. To transfer large data files, data needs to be shared in bulk. Payers need to leverage bulk FHIR APIs to ensure seamless export of member data.

Fig. Payer to Payer Data Exchange Workflow

A payer seeking member data needs to send a request to the primary payer’s API URL for receiving USCDI data files.

1. Payer obtains health data available in FHIR data repository in ready-to-consume format. FHIR data repository is populated with data from payer’s operational data store / enterprise data warehouse
2. FHIR APIs as mandated by CMS guidelines which are implemented and hosted on FHIR server
3. Receiving payer will obtain data as a FHIR message through a bulk FHIR transaction. The received FHIR message will be parsed and transformed
4. The transformed data is ingested into the new payer’s operational data store / enterprise data warehouse. This data can be further pushed to the payer’s FHIR solution and can be accessed by third parties


Key Benefits

  • Member 360 view: Member encounter and lab data along with claims data provides payers with  a holistic view of member health. Insights such as frequency and type of care provided, reason for a specific type of care, medication history, and adherence to care plan can be obtained from historic health data
  • Improved decision making: Members will have the ability to share historic data with their treating providers for efficient and shared decision making. Access to historic data along with a clinical decision support tool enables treating providers to improve their decision making for better treatment and quality care delivery. It also allows members to schedule planned check-ups and receive proper treatment after they switch plans
  • Centralization: Payer-to-payer data exchange removes the barrier of data silos to benefit members and payer organizations, and makes switching health plans coherent

“Payer-to-Payer Data Exchange” allows members to access their holistic health data for informed decision making when they switch between multiple plans, and will also help improve the overall quality of care as member health data won’t be stored in siloed systems.

Read all Blogs in the FHIR Series

Part 1: CMS Interoperability & Patient Access Rule - Impact & Opportunities

Part 2: CMS Interoperability & Patient Access Rule - Patient Consent on Data Sharing

Part 3: CMS Interoperability & Patient Access Rule - Provider Engagement using ‘SMART on FHIR®’ Apps

Part 4: CMS Interoperability & Patient Access Rule - FHIR Bulk Data API

Part 5: CMS Interoperability & Patient Access Rule - FHIR Data Repository

Next in the blog series, Part 7: "SMART on FHIR”.