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Everything you need to know about the Patient Access API including its purpose, who it affects, and when it goes into effect.
What Is The Patient Access API?
Impacted Payers must:
FHIR® API conformant with the technical requirements outlined in 45 CFR §170.215 that supports the delivery of any active member’s clinical, claims, encounter, and prior authorization data, as authorized by the member or their personal representative, to the member or representative selected third-party application. Clinical, claims, and encounter data must be available within one (1) business day from the date received by the payer and prior authorization data must be made available within one (1) business day from the date a request is received or one (1) business day from the date a status update is made to the request.
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?
- July 1, 2022 for clinical, claims, and encounter data
- January 1, 2027 for prior authorization data
What Should You Do Next?
Connect with 1upHealth to learn more about Patient Access API and how we can help you prepare for when it goes into effect.
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