CMS Interoperability Rules Guide

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The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) have released final regulations on interoperability and data exchange across the entire healthcare ecosystem. The purpose is to break down barriers to data exchange in order to promote patient-centric, data-driven healthcare.

Read the CMS Interoperability and Patient Access final rule.

Read the ONC's 21st Century Cures Act final rule.

provided by HealthLX

CMS Interoperability and Patient Access Final Rule Deadlines

To comply with the CMS Interoperability and Patient Access Final Rule, payers need to implement Application Programming Interfaces (APIs) using the Health Level 7® (HL7) Fast Healthcare Interoperability Resources® (FHIR) standard to improve the electronic exchange of health care data.

Read more about interoperability priorities for 2021.

Read ONC's FHIR Fact Sheets.


Patient Access API
Enforcement begins July 1, 2021


Provider Directory API
Enforcement begins July 1, 2021


Payer to Payer
Enforcement is delayed

Core Data Sharing Requirements

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1 Claims & Encounters - Including encounters with capitated or delegated providers.

2 Clinical/USCDI - US Core Data Interoperability.

3 Cost Data - Provider payment amounts and enrollee cost-sharing amounts.

4 Formulary/Preferred Drug List – Implementation Guide to help members select a coverage type during enrollment for the medications they are currently on is HL7 FHIR Da Vinci - PDex US Drug Formulary IG: Version STU 1.0.1.

5 Provider Directory -The Implementation Guide is HL7 FHIR Da Vinci PDex Plan Net IG: Version STU 1.0.0.




Learn about HL7’s Da Vinci Project.

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CMS Patient Access Rule

Payers must make patient health care claims and clinical information available to members through a standards-based API for Medicare Advantage, Medicaid and CHIP FFS, Medicaid and CHIP managed care, and QHPs on the FFES. 




CMS Provider Directory API

Payers must make provider directories available through a standards-based API that is accessible on a public-facing digital endpoint on the payer’s website.


HL7 FHIR Da Vinci PDex Plan Net IG


CMS Payer to Payer API - Enforcement delayed by CMS

Payers will be required to exchange patient USCDI data upon request.



Gartner recently listed HealthLX as a Representative Vendor in enterprise clinical data integration (CDI) in its U.S. Healthcare Payer CIO Top Actions for 2021: Clinical Data Integration via interoperability.

Contact HealthLX to learn more about our long-term leadership in healthcare interoperability and why partnering with us may be your best choice.

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