CMS Rule for Health Plans - Provider Directory



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1upHealth solution for CMS Rule Provider Directory through our FHIR platform


CMS-regulated health plans are required to make provider directory information publicly available via a standards-based API. 1upHealth is well positioned to support health plans in meeting the CMS Patient Access Provider Directory requirements for the July 2021 enforcement deadline. We would build on our platform already in production to quickly and efficiently assist in meeting compliance requirements, as depicted below:

1upHealth Architecture CMS patient access diagram for payer


Provider Directory Requirements

Health plans must make available a FHIR API based list of providers that are in-network. This is the same approach we’ve taken with the public NPPES provider directory FHIR API already on the 1up platform. Mandate details:

  • Data Standard - FHIR 4.0.1 (R4) API, specifically the Da Vinci Payer Data Exchange (PDEX) Plan Network IG
  • Required Data - Provider names and network status, addresses, phone numbers, specialties*
  • Timing - Provider directory updates must be available via API within 30 days of receipt of new data or changes to directory data
  • Security - API endpoint on public website
* MA-PD impacted plans must also make Pharmacy name, Address, Phone number, Number of pharmacies in network, and Type of pharmacy (e.g., “retail pharmacy”).

To support this further, we would deploy documentation and the ability for developers to use the same keys for the patient access API for the provider directory API.


Why 1upHealth


1upHealth is well positioned to support health plans in meeting the CMS requirements for the July 2021 deadline.

Direct Payer Experience

We have direct experience through our work with as one of the first approved Blue Button 2.0 apps, with health plans supporting millions of health plan members and the Da Vinci Project through workgroups and connectathons.

Extensive Clinical Data Network

We've worked with 100s of health systems across the US in meeting Meaningful Use 3 (MU3) requirements. We’ve now connected to 10,000+ hospital and health centers, allowing patients to authorize access to their EHR medical records with 3rd party applications.

We are FHIR Experts

Our team is comprised of leading FHIR experts who have presented alongside CMS and ONC leaders like Don Rucker, had led HL7 standard balloting, and participate in numerous FHIR connectathons

Proven Platform for Regulation

Because our award-winning FHIR solution is already in production, we can ensure timely deployment and meeting the requirements of the new rules.