The Road to Interoperability Series: Patient Access API & Provider Access API

February 15, 2024 1:00 PM - 3:30 PM (EST)

Description

On January 18, 2024, CMS released a pre-publication version of a final rule (the Final Rule) that will require Medicare Advantage organizations (MA or Part C), Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) on the Federally-Facilitated Exchanges (FFEs)(collectively “impacted payers”) to implement a standards-based Patient Access API. According to CMS, the Final Rule changes are designed to improve the electronic exchange of health care data and streamline processes related to prior authorization and medical care. Impacted payers have until compliance dates in 2027 to meet the API requirements in the Final Rule. 

Patient Access API

The Final Rule will require impacted payers to implement a standards-based Patient Access API and information about certain prior authorizations to the data available via that Patient Access API. CMS believes that the Final Rule changes will improve patients’ understanding of their payer’s prior authorization process and its impact on their care. 

Provider Access

The Final Rule also will require impacted payers to implement and maintain a Provider Access API to share patient data with the patient’s in-network providers, and to make the following data must be made available via the Provider Access API: Individual claims and encounter data (excluding provider remittances and enrollee cost-sharing information); data classes and data elements in the United States Core Data for Interoperability (USCDI); and prior authorization information (excluding those for drugs). The Final Rule will also require impacted payers to maintain an attribution process to associate patients with their in-network or enrolled providers and to allow patients to opt out of having their data available to providers. The Final Rule will require impacted payers to provide patients with plain language information about the benefits of API data exchange with their providers and their ability to opt out. 

As part of WEDI's Road to Interoperability and Prior Authorization Educational Series, we invite you to register for our Patient Access and Provider Access API event as we discuss key elements of the API and host an expert panel who will discuss best practices, challenges and more.