What the CMS proposed interoperability and patient access proposed rule means for payers

Download the Fact Sheet

To promote data sharing, CMS released its final rule on March 9, 2020 with the goal of ensuring that every American can, without special effort or advanced technical skills, see, obtain, and use all electronically available information that is relevant to his or her health and care. Most of these rules go into effect beginning on January 1, 2021. They include two types of information:

  • Personal information that requires appropriate diligence to protect each individual’s privacy, such as their current and past medical conditions and care received
  • General interest information that should be widely available, such as health plan provider directory, and in some cases pharmacy directory

What payers are impacted by this rule?
Medicare Advantage (MA) plans, Medicaid state agencies, Medicaid managed care plans, Children’s Health Insurance Program (CHIP) agencies, CHIP Managed Care entities, and issuers of qualified health plans in Federally-Facilitated Exchanges, except for stand-alone dental plans.

What are payers required to do under this proposed rule?
PATIENT ACCESS API: The rule requires covered Health Plans to provide patients access to their data through “open” Application Programming Interfaces (APIs). APIs should be published such that patients can use third-party applications to access that data, subject to the provision of HIPAA.

Data to be shared includes:

  • Available adjudicated claims (including provider remittances and enrollee cost-sharing)
  • Encounters with capitated providers;
  • Clinical data, including laboratory results (when maintained by the impacted payer)

PROVIDER DIRECTORY API: Health Plans must make standardized information about their provider networks available through a Provider Directory API which includes:

  • Provider names, addresses, phone numbers, and specialties
  • For MA plans that offer part D (prescriptions) must include pharmacy directory data, including the pharmacy name, address, phone number, number of pharmacies in the network, and mix (specifically the type of pharmacy, such as “retail pharmacy”)

APIs must be compliant with standards (HL7® FHIR® – Fast Healthcare Interoperability Resources 4.0.1) published in the companion ONC final rule.

The rule also requires payers to support beneficiaries in coordinating their own care via payer to payer care coordination by January 1, 2022 using the United States Core Data for Interoperability (USCDI) data standard.

What standards need to be supported under this rule?

  • FHIR 4.0.1
  • USCDI v.1

What type of data will be shared?

  • X12 message types, X837, X835, and others
  • Clinical data, if already managed by the plan
  • Pharmacy benefit, directory, and formulary data
  • Provider Directory information

Customers use our solutions to bring together patient and member data from EMRs, insurance claim systems, and other sources across the healthcare ecosystem. InterSystems interoperability technology has been at or near the top of KLAS rankings for over a decade.

InterSystems Can Help You Succeed

CMS Rule Requirements and InterSystems Capabilities Chart


Powering Digital Transformation

Digital transformation is a strategic imperative that payers need to embrace if they want to maintain a leading edge. Not only will it help payers envision new approaches to care delivery at lower cost, but will also help steer members to the lowest-cost high-quality provider, thereby optimizing the care setting for their needs and enabling them to better manage their health. And that is at the heart of the CMS rule.

No data management vendor has a greater commitment to healthcare or more relevant experience than InterSystems. Globally, more than a billion health records are managed by solutions built on our technology. The most sophisticated private and government providers depend upon devices, records, and IT powered by InterSystems.

Download the Fact Sheet