CMS interoperability and patient access mandate

May 24, 2021

‚ÄčThe Centers for Medicare & Medicaid Services (CMS) has implemented interoperability final rules that affect Keystone 65 HMO, Personal Choice 65SM PPO, and Keystone HMO CHIP members. The rules include a mandate to allow eligible members greater access to their health care data and improve data sharing between eligible members, their providers, and their health plan.

The mandate includes three parts:

  • Patient Access Plan Data Application Programming Interface (API)
  • Provider Directory API
  • Payer-to-Payer data exchange

Effective, July 1, 2021, your eligible patients will have the opportunity to gain access to their claims and clinical information through their selection of a third-party software application that can connect with health plans to share data.

Read below for more information on the mandate and compliance dates.

CMS enforcement and compliance dates

- July 1, 2021: Patient Access API

- July 1, 2021: Provider Directory API

- January 1, 2022: Payer-to-Payer data  exchange 

Patient Access and Provider Directory APIs

The patient access rule states that Independence must allow active members access to their health information through an API. To meet the requirements of the mandate, Independence has created a process for third-party developers to register their applications with Independence by the July 1, 2021, CMS enforcement date.  

The API gives eligible members the ability to share their personal health information with a third-party application of their choice and make informed decisions about their health care. The requirement for each API and the type of data shared is as follows:

  • Patient Access API:

    Requirement: The Patient Access API must make data available for dates of service on or after January 1, 2016 (for as long as the health plan maintains the data).

    Data type: The type of data includes adjudicated claims, encounters, and clinical data maintained by the health plan.
  • Provider Directory API:

    Requirement: The Provider Directory API must be accessible via a public-facing digital endpoint on the health plan's website. Updates to the directory are required no later than 30 calendar days after a change is submitted.

    Data type: The type of data includes provider demographics, specialties, and affiliated groups.

Payer-to-Payer data exchange

This rule states that Independence must maintain a process for the electronic exchange of a member's clinical data with another health plan when requested by a member.

Specifically, the exchange should allow health plans to:

  • receive data from another health plan spanning up to the previous 5 years the member was insured by them.
  • per the member's request, send their data, during and up to 5 years after their coverage ends, to the new health plan that now insures the member.
  • per the member's request, send their data, during and up to 5 years after their coverage ends, to any other health plan identified by the member or their personal representative.

CMS will enforce compliance of a payer-to-payer data exchange starting January 1, 2022.

Look for more information on payer-to-payer data exchange in future articles.