When providers can access accurate, timely data from payers, patient care improves and collaboration deepens. The new CMS-0057-F Provider Access API brings that vision closer to reality, enabling seamless payer-to-provider data exchange built on modern FHIR standards. But for many organizations, the challenge is not just technical compliance – it’s turning the rule into a real-world advantage.
At 1upHealth, we designed our Provider Access solution to bridge that gap. We focus on making data access meaningful, delivering technology and workflows that enhance provider satisfaction, simplify onboarding, and increase the use of high-quality data at the point of care. Providers gain secure, intuitive access to claims and clinical information, while payers benefit from lower administrative overhead, more engaged provider partners, and improved performance in value-based care programs.
During our recent webinar, “Provider Access: From CMS Rules to VBC Results,” we fielded important questions from payers about how this works in practice – how data flows, how access is controlled, and how trust is built. Below, we share the questions and refined responses that illustrate how 1upHealth is helping payers turn compliance into collaboration.
Provider Onboarding, Access, and Attribution
Q: How is 1upHealth’s provider onboarding process payer-agnostic? Don’t payers need to know where their data is going?
A: 1upHealth’s provider onboarding process minimizes friction for both payers and providers while maintaining visibility and control. Providers register once through our developer portal, where we verify identity, organization, and credentials. Once validated, they can access endpoints for any payer where they have an active attribution relationship.
Even though 1up DevPortal access is payer-agnostic, payers will have complete transparency through the 1up Console, which provides real-time usage reports showing which providers accessed data, when, and how often. This model creates a trusted network that accelerates adoption without sacrificing oversight.
Q: What happens if a member changes providers? How is attribution updated?
A: Attribution lists are managed by payers and continuously updated as care relationships evolve. When a member switches providers, they’ are removed from the prior provider’s list and added to the new one. The 1up Console will reflect these updates in real time as the updated data is ingested.
The future auto-attribution feature will streamline this even further by generating updated attribution lists based on existing claims data housed within the 1up Platform, reducing manual work and improving accuracy.
Q: Does the auto-attribution feature require all claims data to be housed in 1upHealth?
A: Yes. The auto-attribution capability will require claims data to be stored in the 1upHealth environment. Many payers already provide this data for other CMS-0057-F APIs, such as Patient Access or Payer-to-Payer Data Exchange, meaning no additional data integration is required. This reuse of data supports scalability across APIs and increases the overall ROI of a payer’s FHIR investment.
Data Governance and Provider Validation
Q: How are providers validated and vetted?
A: Provider validation follows a rigorous, multi-step vetting process. 1upHealth verifies organizational credentials and user roles before granting API access. Payers can also share pre-approved provider NPIs to speed up validation. Once validated, access is explicitly scoped to attributed members, ensuring data security and compliance.
This approach balances automation with payer control, giving payers confidence that only authorized providers can view member data.
Q: Can 1upHealth enforce completion of a BAA before granting access?
A: CMS does not require a Business Associate Agreement (BAA) for Provider Access APIs, and 1upHealth follows the regulation to maintain CMS compliance.
If there’s an alternative use case the payer is interested in pursuing with a provider, we can help facilitate and enforce the completion of a BAA before enabling access.
Q: How does 1upHealth obtain claims, encounter, and clinical data from payers?
A: Provider Access builds on the same FHIR-native infrastructure as our other CMS-0057-F solutions. 1upHealth securely ingests and normalizes data, including claims, encounters, clinical, and prior authorization records, directly from payer systems. Provider Access then exposes this information through APIs that give authorized providers real-time visibility into member data.
This shared FHIR foundation allows payers to extend value across multiple regulatory APIs while maintaining a single, consistent data model.
Member Consent and Experience
Q: How are members notified about their opt-out rights?
A: Members are automatically opted in to provider data sharing but can opt out at any time. 1upHealth will provide payers with the required education materials, and they can manage this communication with members as they see fit.
Suppose the payer uses 1upHealth’s configurable opt-out experience, which integrates with existing member portals. In that case, the workflow includes educational messaging about the benefits of staying opted in and their right to opt out.
Provider Experience and Data Usability
Q: How can providers efficiently search for data, especially when a member has hundreds of EOBs?
A: Providers need fast, intuitive access to information. 1upHealth’s interface includes advanced search and filtering tools that let users locate specific claims, encounters, or timeframes in seconds. Providers using their own systems via API can apply those same filters programmatically. The result is a user experience that supports both operational efficiency and clinical relevance.
Q: How is “provider” defined? By a single NPI, or can a provider see all of their NPIs?
A: Provider Access is structured flexibly around organization and provider-level NPIs. A provider group interested in integrating at the organization-level can view data associated with multiple NPIs if they fall under the same validated organization. An individual provider looking to access their data would be limited to the information under their individual NPI. This ensures visibility for multi-specialty groups and integrated networks while maintaining strict access boundaries for compliance and security.
A New Era of Payer-Provider Collaboration
Provider Access is reshaping how payers and providers collaborate. The webinar discussion underscored a common theme: data transparency builds trust. When providers can easily access accurate, timely data, administrative friction is reduced and care decisions improve. For payers, that translates into enhanced quality reporting, fewer manual data requests, and stronger relationships with their network provider partners.
More importantly, the ROI of Provider Access extends beyond cost savings. With unified data pipelines, payers gain actionable insight into provider performance and member outcomes. This visibility drives value-based care adoption and creates a feedback loop where data fuels continuous improvement.
1up Provider Access makes this vision achievable today. By combining modular FHIR APIs, secure provider onboarding, and real-time data access, we enable payers to meet CMS-0057-F requirements while creating a foundation for long-term success. The future of payer-provider collaboration starts with data that is accessible, trusted, and used to improve care.
Learn More About 1up Provider Access
If you missed our Provider Access webinar, you can watch the recording here or contact us to learn how 1upHealth can accelerate your Provider Access implementation.