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1up AnalyzePayer-to-Payer Data Exchange on FHIR®
Everything you need to know about the Payer-to-Payer Data Exchange on FHIR® including its purpose, who it affects, and when it goes into effect.
What Is The Payer-to-Payer Data Exchange on FHIR®?
Impacted Payers must:
(a) within one (1) week of the start of coverage for new members or on or before January 1, 2027 for current members, develop and maintain a process that allows members to identify their previous and/or concurrent payer(s) and to opt into data sharing via the Payer-to-Payer Data Exchange API. For any previous or concurrent payer identified by the enrollee, the impacted payer must request that enrollee’s data from such identified payer(s) no later than one (1) week after the payer has obtained the necessary permission and/or information; and
(b) maintain a FHIR® API conformant with the technical requirements outlined in 45 CFR §170.215 that supports the delivery of any member’s clinical, claims, encounter, and prior authorization data that is maintained by the payer to the member’s current health plan within one (1) business day from the date of a valid request for such information by the member’s current payer.
All data classes included under the content standard in 45 CFR 170.215 [currently USCDI v.1 until 2026, then USCDI v.3] for any encounter with a date of service within five (5) years from the date of the request.
Any data related to a prior authorization request and decision for any active prior authorization or for any prior authorization request where the date of last status change was less than one (1) year.
Prior Authorization Data includes: Date of Approval (and for how long such approval remains valid); items and/or services approved; Any other documentation sent by the provider in support of the prior authorization request, including but not limited to structured or unstructured clinical notes, lab results, scores or assessments, past medications or procedures, progress notes, or diagnostic report.
Any data concerning adjudicated claims, including claims data for payment decisions that may be appealed, were appealed, or are in the process of appeal, with a date of service within five (5) years from the date of the request.
Any encounter data from capitated providers with a date of service within five (5) years from the date of the request.
Who Does This Impact?
- Medicare Advantage (MA)
- Medicaid
- Children’s Health Insurance Program (CHIP)
- Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs)
When Does It Take Effect?
- January 1, 2027
