1. . CMS 9115. 1 The rule requires health plans under certain government programs, like Medicare Advantage, Medicaid, and Qualified Health Plans on the Federally Facilitated Exchanges, to have the capability . This FHIR based Implementation Guide was developed by the DaVinci Project in coordination with the HL7 Financial Management Workgroup. 1. implement more sophisticated payer-to-payer data exchange solutions. The CMS regulations include policies which require or encourage payers to implement Application Programming Interfaces (APIs) to improve the electronic exchange of health care data - sharing information with patients or exchanging information between a payer and provider or between two payers.

CMS is issuing new guidance on data exchange provisions included in its May 2020 . The payer-to-payer data exchange provision of the agency's interoperability rule had been slated to go into effect Jan. 1, 2022. . current payer. Nick Moran - Friday, September 17th, 2021 Print | Email. This standards-based API must be conformant with specific implementation guides. This payer-to-payer data exchange requires these payers, as finalized at 42 CFR 422.119(f) for MA organizations, at 42 CFR 438.62(b)(1)(vi) . This is the current published version. The data that payers exchange is, at minimum, U.S. Health insurance providers have just started to go live on the first phase of the CMS Interoperability Rule, implementing the Patient Access and Provider Directory APIs. Payer-to-Payer Data Exchange - Coordinate care between payers by exchanging, at a minimum, the information contained in the United States Core Data for. Part of this rule requires health plans to enable Payer to Payer Data Exchange by January 1st, 2022. It required many payers to allow a current or former member to. The ONC rule specifies the interoperability data and technology standards for sharing medical records between patients, providers and payers. Section 1.3 Payer-to-Payer Data Exchange CMS envisions that patient health care data will be easily exchanged as patients move between different health plans and at . Information Standard - Not unequivocally indicated by CMS.

It is being prepared for an early ballot in September 2019 where comments are being reviewed. Q3: Why is CMS exercising enforcement discretion for the payer-to-payer data exchange provisions of the CMS Interoperability and Patient Access final rule (CMS-9115-F)? This Payer-to-Payer Data Exchange is an outcome of the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access Final Rule. As we kick off 2022, one of the big questions surrounding interoperability is the status of the payer-to-payer data exchange rule. Aetna will also send data it has received from other health plans through the Payer-to-Payer Data Exchange. Payer-to-Payer Data Exchange (Originally required Jan 1, 2022 - Currently Delayed) - CMS-regulated payers are required to exchange certain patient clinical data at the patient's request with other payers. 1upHealth can help you address new CMS Patient Access Rule compliance through our FHIR platform. CMS notes that future rulemaking may require this payer-to-payer data . Watch this webinar as industry experts will discuss the challenges associated with the existing regulation but also offer solutions developed by the HL7 Da . PayertoPayer.com is led by Onyx's Chief Interoperability Officer and CMS Blue Button Innovator, Mark Scrimshire who is the co-chair of the HL7 Payer Data Exchange Workgroup and author of the Da . Practical Considerations on CMS 9115 Payer-to-Payer Data Exchange. "We anticipate providing an update on any evaluation of this enforcement . The Payer Data Exchange (PDex) Implementation Guide (IG) is provided for Payers/Health Plans to enable them to create a Member's Health History using clinical resources (based on US Core Profiles based on FHIR R4) which can be understood by providers and, if they choose to, committed to their Electronic Medical Records (EMR) System. Dates: Jul 27, 2021. The Interoperability and Patient Access final rule (CMS-9115-F) defines ''maintain'' to mean the impacted payer has access to the data, control over the data, and authority to make the data available through the API (85 FR 25538). Published Jul 13, 2021. For a full list of available versions, see the Directory of published versions. Payer-to-Payer Exchange. Compliance date: January 1, 2022. This means that years of healthcare data, that was made available through the Patient Access API, can now be exchanged between payers and enable: CONTACT SALES CMS recently released its FY 2021 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospitals (LTCH) proposed payment rule (CMS-1735-P). The January 1st deadline for implementing the Payer-to-Payer exchange is fast approaching and payers are looking for practical information on how to meet the rule's requirements. payer-to-payer data exchange requirement. 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. Join the Da Vinci Project next Wednesday at its July Community Roundtable titled "Payer-to-Payer Data Exchange: Rising to the Opportunities and the Challenges." The session will focus on the use of HL7's 's Fast Healthcare Interoperability . What does this mean for Payers? CMS Rule Interoperability Mandate for Payers. The Centers for Medicare and Medicaid Services (CMS) is tackling this problem through the Interoperability and Patient Access Final Rule. First, CMS proposes to extend the payer-to-payer data exchange to state Medicaid and CHIP FFS programs; Second, CMS is proposing to enhance this payer-to-payer data exchange triggered by a patient's request: CMS would require an FHIR-based API for this data exchange. Plans must be able to share pertinent healthcare information (including some clinical data) with other plans when a patient changes insurance carriers and chooses to request this information be shared with the new plan. "We anticipate providing an update on any evaluation of this enforcement . To provide payers with flexibility to support timely adoption and rapid implementation, CMS did not require an application programming interface (API) or any a specific mechanism for the payer-to-payer data exchange. Payers must be able to send and receive clinical USCDI V1 data to and from another health plan, at the members (patient's) request. The final rule also includes a provision on payer-to-payer data exchange that does not require the use of an API, but Mugge said CMS might consider this in the future.

The payer who is sending the data (Payer 1) must share it via an API infrastructure that is specific for Payer to Payer Data Exchange. The Payer to Payer Exchange API enables data to follow individual patients across disparate health plans, ensuring that no information is lost. The Payer to Payer Exchange API enables data to follow individual patients across disparate health plans, ensuring that no information is lost. In the recently concluded 2021 CMS HL7 FHIR Connectathon, our CIO, Mark Scrimshire, who is also the co-chair of the Payer Data Exchange workgroup and author of the Da Vinci Payer Data Exchange Implementation Guide (IG), shared his expert views on the Payer-to-Payer Data Exchange Implementation Guide focusing specifically on the forthcoming regulatory target of January 1, 2022. What payers need to know about CMS' Payer-to-Payer Data Exchange requirement As plans struggle to decide how to comply with a badly-worded portion of the final rule on interoperability, they should. Payer to Payer Data Exchange is a component of the CMS Patient Access and Interoperability Rule, and builds on the preceding Patient Access API requirements (enforced from July 1, 2021). What We Know about the Payer to Payer Data Exchange On January 1, 2022, health plans regulated by CMS must exchange the USCDI v1 data set, in electronic form, at the patient's request, which is a one-time send. 1upHealth supports both the ability to complyto the regulations and leveragethe newly available clinical data from other health plans. Data exchange is only initiated if a health plan . The Centers for Medicare & Medicaid Services' (CMS') new interoperability rule will require major changes for payers and hospitals to provide patients access to their health information. The Centers for Medicare & Medicaid Services will continue to exercise discretion in enforcing compliance with the payer-to-payer data exchange provisions of its 2020 final rule on interoperability and patient access until it finalizes future rulemaking to address implementation challenges, the agency announced today. The Biden administration has delayed enforcement of payer-to-payer data exchange included in a May 2020 final interoperability rule until future regulations are finalized | CMS is delaying . Payers need to leverage bulk FHIR APIs to ensure seamless export of member data. ET to Feature Payer-to-Payer Data Exchange. In total, 175 health plans will be available, up from 132 in 2018. Click to see the most frequently asked questions about getting compliance for the payer to payer data exchange rule under the CMS Interoperability Final Rule. Medicaid FFS and CHIP FFS are not subject to Payer-to-Payer Data Exchange, but other than that the requirements are largely the same across plan types. Payer to Payer Data Exchange: The last article discussed the challenges . ; The proposed rule increases payments to acute care hospitals, proposes to "clarify, update, and codify" Medicare bad debt policies, adopts newer wage index delineations, and creates a new code and payment for CART-T cell therapy. The agency's decision to exercise enforcement discretion for the payer-to . Payer 2 . Data Standard - Not explicitly specified by CMS. Aetna will send certain clinical data it maintains on the member, if any, going back to 1/1/2016. Payers must be able to send, receive, and incorporate enrollee USCDI data from the period they were covered, from January 1st, 2016, and for up to 5 years after coverage ends. PDex Implementation, Actors, Interactions, Data Payloads and Methods. In the Interoperability and Patient Access final rule (CMS-9115-F), we finalized a requirement that, at a patient's request, CMS-regulated payers must exchange certain patient health information, and maintain that information, thus creating a longitudinal health record for the patient that is maintained . HL7 Da Vinci Roundtable on July 28 from 4:00 to 5:30 p.m. The requirement was part of the May 2020 Final Rule supporting the 21st Century Cures Act, and its enforcement was scheduled to start on January 1. Key FHIR concepts Payer-to-Payer Data Exchange provision. Payer Data Exchange: Providers need access to payer information regarding current and prior healthcare services received by the patient to more effectively manage the patient's care . On December 8, 2021, CMS announced the publication of a Federal Register Notice (FRN CMS-9115-N2) to formalize its decision to exercise enforcement discretion not to take action against certain payer-to-payer data exchange provisions of the May 2020 Interoperability and Patient Access final rule (see FAQs associated with this decision). Getting ready for payer-to-payer data exchange as part of the CMS Interoperability mandate? The focus of this use case is on the exchange of provider- and payer-originated information to improve patient care and reduce the burden on providers and payers. Fig. As such, where the CMS Interoperability and Patient Access rule requires payers . The CMS Mandate for healthcare interoperability requires a payer-to-payer data exchange by January 1, 2022. 1upHealth's FHIR API Platform is the first true implementation of the ONC's intent for healthcare interoperability. We've dug into the interoperability rules . The payer who is sending the data (Payer 1) must share it via an API infrastructure that is specific for Payer to Payer Data Exchange. The Centers for Medicare and Medicaid Services has announced that it will not take enforcement action against certain payers for the payer-to-payer data exchange provision of the May 2020 Interoperability and Patient Access final rule until future rulemaking is finalized. Examples of meaningful data flow: When a patient ages into Medicare When a patient changes health plan When a patient is dually-eligible for both MA plans and Medicaid managed care plans The Da Vinci Project began in September 2018 to accelerate the standards required to advance value-based care through the use of HL7 FHIR. Twenty additional payers will sell individual health plans in states using the federal health insurance exchange platform. payer-to-payer data exchange: cms-regulated payers are required to exchange certain patient clinical data (specifically the u.s. core data for interoperability (uscdi) version 1 data set) at the patient's request, allowing the patient to take their information with them as they move from payer to payer over time to help create a cumulative health Payer-to-Payer Data Exchange on FHIR. CMS encourages payers to follow industry best practices to map data that a payer maintains as part of an enrollee's record as a discrete data element to USCDI data elements or a FHIR resource and make it available through the Patient Access API. While we encouraged the use of a FHIR-based API for this data exchange, we did not require it. accordingly, to ensure payers are in a position to effectively contribute toward our shared goals for interoperability, cms recently exercised enforcement discretion with regard to the payer-to-payer data exchange provision, meaning the agency will not take any action against payers should they not meet the original deadline until cms can improve This data must be shared within a single, comprehensive file for the individual patient. The Payer-to-Payer exchange was one part of the final rule related to CMS/ONC interoperability from the 21 st Century Cures Act. Payers are only required to make the data that they maintain in their systems available through the Patient . Get live by the required deadline, Jan 1, 2023! This is part two (updated) of a three part series on the recent CMS proposed and finalized data-exchange requirements. The payer who receives the data (Payer 2) must incorporate it with their pre-existing data of that same patient. If so, your priority as a payer is to address the need to aggregate your members' data from various former payers. Achieving Interoperability This exchange of health information must be facilitated through an API. APIs can connect to mobile apps or to a provider . Payer to Payer Data Exchange | 1upHealth Payer to Payer Data Exchange Learn about CMS Payer to Payer Data Exchange APIs, Interoperability, and additional FHIR requirements for health plans. Deadline for Payer to Payer Data Exchange Final Rule. CMS won't enforce payer interoperability rules. As of January 1, 2022, CMS Payers must comply with patients' requests to send their clinical data, inclusive of the elements defined in the United States Core Data for Interoperability (USCDI) version 1 data set, to other CMS Payers, to ensure that the new payer has patients' complete records if they change plans. Summary of Payer to Payer CMS Interoperability Rule Understand the compliance requirements and find the key deadline to comply with the CMS mandated Payer to Payer Data Exchange Policy CMS regulated health plans must share clinical data (USCDI v1) to another health plan at the members request. These data are available to patients to help them make more informed decisions. CMS Delays Payer-to-Payer Data Exchange but Prior Authorization Rules Remain on Track September 23, 2021 On Sept. 17, the Centers for Medicare & Medicaid Services (CMS) announced that it's delaying an interoperability rule governing how payors are expected to exchange with one another. interoperable payer-to-payer data exchange, CMS is exercising . Da Vinci Payer Data Exchange (PDex) Implementation Guide. This data must be shared within a single, comprehensive file for the individual patient. The payer who receives the data (Payer 2) must incorporate it with their pre-existing data of that same patient. Time: 1:00 pm EDT. This data must be shared within a single, comprehensive file for the individual patient. These data specifications break down electronic health record system silos so records can follow a patient from provider to provider and payer to payer. The payer who receives the data (Payer 2) must incorporate it with their pre-existing data of that same patient. Core Data for Interoperability (USCDI) version 1. A payer is only required to send data received under this payer-to-payer data exchange requirement in the electronic form and format it was received." CMS allows payers to use multiple methods for the electronic exchange of this information, including use of APIs or an HIE. 1 data set standard to enable payer-to-payer data exchange by January 1, 2022. The agency is committed to requiring payer-to-payer data exchange, but "the policy that CMS finalized did not quite hit the mark," Brooks-LaSure said Tuesday. This will allow healthcare patients to take their health information with them as them move from a Sending Plan to a Receiving Plan . This measure further supports the ability of patients to easily . Today, Blue Button 2.0 contains 4 years of Medicare Part A, B, and D data for 53 million Medicare beneficiaries. Payer-to-Payer API: We are now proposing to enhance the previously finalized payer-to-payer data exchange requirements for impacted payers by requiring that such exchange be via a FHIR-based Payer-

While there's no requirement to follow any kind of standard, applying FHIR to exchange this data is encouraged. 2. To promote data sharing, CMS released its final rule on March 9, 2020 with the goal of ensuring that every American can, without special effort or advanced technical skills, see, obtain, and use all electronically available information that is relevant to his or her health and care. This Payer-to-Payer Data Exchange is an outcome of the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access Final Rule. The CMS Rule encourages interoperability, innovation and patient empowerment by requiring payer-to-payer data exchange, implementing the ONC's API standards, adopting conditions of participation (CoP) notice requirements, and publicly reporting providers that may be information blocking . The purpose of this guide is to support two scenarios: 1 .

Member Request. Payer-to-Payer Data Exchange. 1 The rule requires health plans under certain government programs, like Medicare Advantage, Medicaid, and Qualified Health Plans on the Federally Facilitated Exchanges, to have the capability . CMS 2022 - 07 Da Vinci Payer Data Exchange (PDex) & Drug Formulary) Short Description Long Description Type Track Lead(s) Track Lead Email(s) Specification Information Call for participants Zulip stream Testing Scenario: Short Description Payer Data Exchange with Members, Other Payers and Providers & end-to-end testing of theDaVinci Payer . This page is part of the Da Vinci Payer Data Exchange (v1.0.0: STU 1) based on FHIR R4. To transfer large data files, data needs to be shared in bulk. Cures Compliance for Health Plans Below is a high-level overview of the requirements for health plans in the 474 page rule with some thoughts on operational and strategic implications. Specifically: Receive Member Data Payer-to-Payer Data Exchange . Payer-to-Payer Exchange.

. The Centers for Medicaid and Medicare Services (CMS) has been working with HL7 and other industry partners to ensure that implementation guides and other resources are freely available to payers to use . + Follow. "Our interoperability rule wasn't. On the off chance that a payer gets information for the payer-to-payer data exchange using an API, they can then make this information accessible through the Patient Access API, however, the payer won't be needed per this last guideline to take information from another payer and set . Click to see the most frequently asked questions about getting compliance for the payer to payer data exchange rule under the CMS Interoperability Final Rule. Payer 2 . Payer to Payer Data Exchange Workflow. Most of the rule's mandates for payers go into effect beginning on January 1, 2021, although CMS has extended . Beyond payer-to-patient data sharing, by 2022 CMS-regulated payers must be ready to exchange patient clinical data between themselves on an enrollee's request. Rather, we required impacted payers to receive data in The Centers for Medicare & Medicaid Services will continue to exercise discretion in enforcing compliance with the payer-to-payer data exchange provisions of its 2020 final rule on interoperability and patient access until it finalizes future rulemaking to address implementation challenges, the agency announced today. Meet the CMS Regulations For Payer 2 Payer APIs Payer to Payer Data Exchange CMS requires health plans to enable payer to payer data exchange for their former members with up to 5 years of historical data. A Complete Payer to Payer Data Exchange Solution With over 40 health plans using 1upHealth to meet the CMS Payer to Payer Mandate and years of work connecting to health systems, 1upHealth brings experience to not only comply with the regulations, but also ensure your plan and members get the most from the new data interoperability interfaces .

An upcoming proposed CMS rule "Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients' Electronic Access to Health Information" (CMS-9123-P), suggests that the Payer to Payer Data Exchange will occur at the time of member enrollment and be expanded beyond just clinical (USCDI v1) data. While this mandate focuses on empowering members, it also makes payers rethink how member data needs to be aggregated and distributed. Aetna may send data from before 1/1/2016 in some instances. Payer-to-Payer Data Exchange. A payer seeking member data needs to send a request to the primary payer's API URL for receiving USCDI data files. The CMS Interoperability and Patient Access final rule finalizes requirements in 42 CFR 438.62(b)(1)(vi) and (vii) for the creation of a process for the . CMS-regulated health plans must enable Payer to Payer Data Exchange by January 1st, 2022. In 2020, the average premium for the second-lowest cost silver plan on HealthCare.gov will decrease by 4 percent for a 27-year-old. However, in September CMS delayed enforcement pending future .