Pioneering Bidirectional Data Exchange for Mandatory Compliance and Beyond

This presentation will spotlight insights and advancements from a payer-to-payer data exchange cohort, comprising three health plans. It will delve into the challenges and efficient methods for establishing member data exchange among cohort members. This initiative is in alignment with Centers for Medicare Medicaid Services regulations, including the Interoperability and Prior Authorization Final Rule (CMS-0057-F), mandating impacted payers to implement and maintain payer-to-payer application programming interfaces (APIs) for exchanging clinical, claims and prior authorization data when a consumer moves between health plans. While the initial implementation of FHIR APIs marks a critical first step, the true hurdle lies in constructing a seamless data flow infrastructure. Leveraging HL7’s Da Vinci PDex Implementation Guides, the cohort tackled technical intricacies and real-world challenges. Regular workshops convened technical teams from each health plan, concentrating on executing payer-to-payer data exchange strategies. The cohort aims to reduce reliance on point-to-point connections, streamline processes and ensure compliance with evolving standards.