At 1upHealth, we believe payer-to-payer data exchange is about far more than regulatory compliance. It’s an opportunity to fundamentally change how payers onboard members, coordinate care, and unlock the full value of their data.
Our approach to CMS-0057-F is designed with that philosophy in mind. Rather than simply checking the compliance box, we focus on creating infrastructure and workflows that help payers improve member experiences, streamline operations, strengthen quality reporting, and drive measurable ROI.
During our recent webinar, “Payer-to-Payer Data Exchange: From Rule to Results,” we shared how 1upHealth is building the most comprehensive, scalable, and future-ready solution for payer-to-payer interoperability. The discussion sparked thoughtful questions from attendees about endpoint connectivity, consent workflows, member matching, and data strategy.
Below, we’ve curated and polished those questions and our answers to help guide your organization as you prepare for payer-to-payer data exchange and look beyond compliance to long-term value creation.
Network Development and Endpoint Connectivity
Q: How is 1upHealth addressing external payer endpoint discovery?
A: Discovering and connecting to external payer endpoints is one of the most challenging aspects of payer-to-payer data exchange and also one of the most important. At 1upHealth, we approach it on several fronts.
We participate in leading industry initiatives such as the HL7 Da Vinci Project, The Sequoia Project, and FHIR Connectathons, where endpoints are first surfaced and tested.
We also conduct direct outreach to payers and collaborate closely with our customers to prioritize integrations with high-value partners in their markets. If/when a national network of payers becomes available, we will also use this as a source for endpoint discovery and contribute our own endpoints.
Just as importantly, we go beyond discovery. Endpoints change over time, specifications evolve, and credentials must be updated. Our team uses automation and agentic AI tools to continuously monitor endpoints, flag issues, and update configurations to keep connections stable. This ensures that once established, your network remains reliable and ready to deliver value without constant manual intervention.
Q: By when do you expect to be connected to most payer endpoints?
A: The industry is at varying stages of readiness. Some payers are already building and starting to test APIs, while others may wait until closer to the January 1, 2027 deadline. Our goal is to establish as many connections as early as possible, well before enforcement begins.
You also don’t need to wait for every payer to be live. We can capture member opt-ins today and queue data requests so that when a new endpoint becomes available, historical data is retrieved automatically. Because each new integration benefits the entire 1upHealth network, your connectivity footprint grows steadily over time.
Q: CMS-0057-F technically applies only to certain lines of business. What’s the value if most of our population isn’t covered?
A: While the regulation focuses on Medicare Advantage, Medicaid, CHIP, and QHPs, many payers are extending payer-to-payer data exchange beyond the minimum requirements because of the value it delivers. Expanding API-based data sharing improves care coordination, enhances quality measurement, supports better risk adjustment, and strengthens member engagement across the entire book of business.
Even if the initial scope is limited, building the infrastructure now positions your organization to scale quickly as adoption grows. We also recommend targeting members who stand to gain the most from payer-to-payer; those with chronic conditions and a greater need for specific benefits and resources. This correlates well with members in Medicare Advantage who are covered by the CMS-0057 Final Rule, compared to typically younger, healthier members with commercial insurance who are not.
Payer-to-Payer Implementation and Roadmap
Q: What are the timelines for your payer-to-payer product being available in QA and production?
A: Our solution is being delivered iteratively in stages. Outbound APIs that allow you to respond to data requests as a prior payer are already live. Inbound workflows for retrieving historical data are actively in development, with broader availability expected in H1 2026.
Even before endpoints are fully live, you can start key parts of your implementation, such as capturing consent and setting up data ingestion pipelines. This early work accelerates your readiness and ensures you’re prepared to go live as the network expands.
Q: If we already have a FHIR server, can we still use 1up’s APIs, network, and consent flows?
A: Absolutely. Our solution is modular, so you can use the components that make the most sense for your environment. Some payers choose to leverage 1upHealth solely for network connectivity, consent management, or inbound data retrieval, while continuing to store and manage data in their own infrastructure.
We can deliver acquired data directly to your existing systems, whether they are on premise or in the cloud. This flexibility allows you to preserve your current investments while still benefiting from our managed services and growing network.
Member Matching, Linking, and Consent
Q: Are you leveraging a third-party Enterprise Master Patient Index (EMPI) for patient matching?
A: We’re building our own EMPI for managing patient identity. Because member consent is required before any data exchange occurs, we can reliably match individuals using identifiers they provide, such as member ID, demographics, and prior plan information.
We follow the FHIR Member Match operation to confirm deterministic matches before exchanging data. In some cases, we can also layer in additional identity resolution techniques to further strengthen matching accuracy.
Q: How are Explanation of Benefits (EOBs) and other data from previous plans linked to the current patient record?
A: Accurate data linking is essential for payer-to-payer success. Once a member opts in, we know exactly who they are in your system and can map their prior data accordingly, even if identifiers differ across payers. We combine deterministic matching, master patient indexing, and source tagging to ensure every piece of data is correctly associated with the individual. The result is a unified longitudinal record that can be trusted across care management, risk adjustment, and analytics workflows.
Q: What happens if a member revokes their opt-in?
A: Members have complete control over their consent and can revoke it at any time. Once they do, we immediately update their status and stop retrieving new data. Data obtained while the member was previously opted in remains valid under CMS rules and can continue to be used. If your organization prefers to delete that data when consent is revoked, we can support that as well.
Q: Are you doing anything outside native FHIR to link historical data?
A: FHIR is the foundation of our platform and our preferred standard for storing, transmitting, and exchanging data. However, healthcare data is diverse and not everything fits neatly into FHIR. We support integration with HL7 v2, proprietary data models, and legacy warehouses to meet you where your data lives. This approach ensures seamless interoperability without costly migrations or disruptions to existing workflows.
Payer-to-Payer Webinar Strategic Takeaways
Payer-to-payer data exchange is not just a compliance milestone. It’s a foundational shift in how health plans operate, compete, and deliver value. During our webinar, one theme surfaced repeatedly: When data follows the member, everyone wins.
Members receive more coordinated care because their new plan starts with a complete picture of their medical history. Providers can make better decisions faster because key clinical and claims information is available from day one. And payers themselves are positioned to act more strategically, with richer insights that improve care management, refine risk adjustment, and enable more targeted outreach.
The implications go even deeper. Historical data flowing in at scale will power more advanced analytics, enabling payers to identify trends in utilization, predict member needs, and personalize engagement in ways that were not possible before. It will also make transitions between payers more seamless, reducing member abrasion during onboarding and strengthening satisfaction and retention.
Equally important, payer-to-payer data exchange sets the stage for future innovation. As the industry adopts standardized, high-quality data exchange infrastructure, payers can build on that foundation to streamline prior authorization, integrate with provider workflows, and ultimately participate in a more connected, value-based ecosystem.
At 1upHealth, our vision is to make all of that possible. We’re not just helping organizations meet a regulatory requirement. We’re creating the infrastructure, network, and workflows that will turn payer-to-payer data exchange into a strategic advantage for years to come.
Learn More about Our Approach to CMS-0057
If you missed the webinar, you can watch the recording or contact us to explore how 1upHealth can accelerate your payer-to-payer readiness. And stay tuned for our upcoming session on Provider Access APIs, another key component of the CMS-0057-F landscape.