top of page


CMS Patient Access API

Q: What data needs to be included in the Patient Access API and the Provider Directory API?

A: CMS expects that data which a health plan maintains and has control over as well as permission to share, is made available. The data CMS is asking to be shared in the Patient Access API is Claims/Encounter data, United States Core Data for Interoperability (USCDI) data elements, Provider directory data such as name, address, specialty and contract status. CMS also requires a plan’s formulary to be made available in the Patient Access API.

Q: What data is recommended to be included first?

A: The guidance from CMS has been to look at the intention of the rule. They want data made available to consumers so that they can take control of their health. We recommend that payers focus first on getting base payer data into the API. This includes patient demographic, coverage, provider, formulary, claims and encounters. Many plans also have clinical data which they maintain that fall into the USCDI data groupings. They should look at this data and determine how to make this data available once they have tackled the basic payer data set above. Looking at this data set also is a good opportunity to look at pre-authorization data, which will be required in the next set of rules once they are finalized.

Q: Are payers required to convert unstructured documents like PDFs or scanned documents to Fast Healthcare Interoperability Resources (FHIR) to support the clinical data exchange requirements of the Patient Access API?

A: CMS does not require payers to manually go through these types of files that cannot be parsed into data elements efficiently for the purposes of this API. The final rule did not require payers to include these large files as data available via the API.

Q: What resources are available to health payers when developing Patient Access APIs? Are there implementation guides available?


CMS Provider Directory API

Q: As a payer, what do I need to know about the provider requirements and their impact on my business and members?

A: Most payers should be able to fulfill this requirement without significant effort. They must make provider directory information available with monthly updates. The Provider Directory API requires information about in-network providers and pharmacies, information which most payers already provide to their members.

Q: What data needs to be included in the Patient Access API and the Provider Directory API?


  • The Patient Access API requires data from claims, encounters, formulary and clinical data as detailed by the United States Core Data for Interoperability (USCDI) version 1:

  • The Provider Directory API requires data about the provider, including name, location, network, insurance plan, organization affiliation and practitioner role. This is generally information about their specialties, if they are accepting new patients, the network to which they belong. This is the same information required for printed directories.


Q: When developing Provider Directory APIs, are there implementation guides payers can refer to?

A: See above (

CMS Payer to Payer API

Q: What should payers be doing now that the payer-to-payer enforcement is delayed?

A: On September 15th, CMS stated they are not enforcing this mandate until after they have had the opportunity to finalize the proposed burden reduction rule. However, we must move forward for the sake of interoperability. Learn about HealthLX's position on this matter in this blog.

Q: What data will payers be required to exchange?

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

Q: How will the new health plan know what endpoint, contact info, etc. in order to reach out to the old health plan and get the member's previous data? For example, will there be a directory of health plan endpoints?

A: A directory of health plan and application endpoints has been envisioned by CARIN Alliance, as well as the FHIR At Scale Taskforce (FAST) workgroup; however, the build of a national endpoint directory has not started. There are a few vendors who have created or are working on creating a directory including the Council for Affordable Quality Healthcare (CAQH) with the help of Edifecs.

bottom of page