CMS Rule for Health Plans - Payer to Payer Exchange



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1upHealth solution for CMS Rule Payer to Payer Exchange through our FHIR platform


CMS-regulated health plans are required to exchange certain patient clinical data (specifically the U.S. Core Data for Interoperability, USCDI, a spec on top of FHIR) with new health plans at the patient’s request. 1upHealth is well positioned to support health plans in meeting the CMS Rule Payer Exchange requirements for the January 2022 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


Payer to Payer Data Exchange Requirements

Payers are required to exchange patient data at the member’s request so members can take all their data with them as they move between health plans. While this is the only requirement to take effect in 2022, thereby giving health plans an extra 6 months, we strongly recommend considering an integrated, all-in-one solution that meets all 3 aspects of the rule holistically: Patient Access API, Provider Directory API, Payer to Payer Data Exchange. Mandate details:

  • Who - MA organizations, Medicaid managed care plans, CHIP managed care entities, QHP issuers on the FFEs
  • Scope - Enrollee/member data within the previous 5 years, when requested by the member/patient
  • Required Data - Clinical data specified under U.S. Core Data for Interoperability (USCDI) version 1. The USCDI data set is basically FHIR resources with specific attributes and coding terminologies required including Medications, Conditions, Procedures, Observations, etc. Clinical Data (in USCDI v1) HL7 FHIR® US Core Implementation Guide STU 3.1.0
  • Data Standard - Not explicitly specified by CMS. If a payer receives data for the payer-to-payer data exchange via an API, theycanthen make this data available via the Patient Access API, however, the payer will not be required per this final rule to take data from another payer and prepare it to be shared via the Patient Access FHIR-based API. They must be prepared to share the data with a new payer, if requested by the patient, in the electronic form and format received
  • Data Ingestion - Health plans must incorporate prior payer data into current member records. This does not require that the payer treat or rely on these data as its own, but must include this data in the record it maintains for each enrollee.
  • Clinical Data Exchange - Payers encouraged to consider using the proposed API infrastructure as a means to exchange health information for other health care purposes, such as to health care providers for treatment purposes.

We propose building on top of the FHIR APIs and infrastructure from the Patient Access API requirement to support this requirement for payers and their members.


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.