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Everything you need to know about the Provider Access API including its purpose, who it affects, and when it goes into effect.
What Is The Provider 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 to an in-network or enrolled provider who has a verified treatment relationship with such member within one (1) business day from the receipt of a valid request for such information by the provider. Data shall only be shared with a provider via the Provider Access API if (a) the member to whom the data pertains is attributed by the payer to the provider; (b) the member has not opted out of data sharing via the Provider Access API; and (c) the provider is part of the payer’s network of providers, as evidenced by either a written contract, or in the case of Medicaid and/or CHIP where such provider is enrolled with the state as a Medicaid/CHIP provider.
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 on or after January 1, 2016.
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
What Should You Do Next?
Connect with 1upHealth to learn more about the Provider Access API and how we can help you prepare for when it goes into effect.
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