Interoperability and Prior Authorization

The final rule:

• Seeks to reduces administrative burden
• Improves transparency into payer requirements
• Accelerates prior authorization decisions
• Supports standardized electronic workflows

There are five different types:

• Patient Access
• Provider Access
• Prior Authorization
• Payer-to-Payer
• Provider Directory

As of Jan. 1, 2027, you’ll be able to access the Prior Authorization API and Provider Access API through your electronic heath records systems. Your group’s application developers will need to connect your group EHR to the APIs to allow the electronic exchange of data. To access the Provider Access API, we will also apply a process to determine which of our members have a treatment relationship with you and also have not opted out of this data exchange with you.

The Patient Access API allows members to access their claims and encounter information, including cost, as well as a defined subset of their clinical information through third-party applications of their choice. Claims data, used in conjunction with clinical data, can offer a broader view of members’ interactions with the health care system, leading to better decision-making and better health outcomes. 

This API shares specific member information with in-network providers with whom the member has a treatment relationship. It provides a complete picture of the member’s history by consolidating information so providers can better coordinate quality of care, including:

• Clinical information such as diagnoses, lab results and procedures
• Claims and encounter data, minus provider remittances and enrollee cost-sharing information
• Notes and other documentation to support care management, follow-up and gap closure efforts

This API allows you to access a payer’s system through your EHR to determine whether prior authorization is required for certain services and allow you to submit a prior authorization and exchange prior authorization decisions − such as  approved, pending or denied.

This API allows health plans to securely share a member's health information when the member switches to a new payer or is covered by more than one health plan.

This API shares data regarding the health plan’s network of contracted providers and pharmacy directory information.

Member information may come from various sources including payers and providers. Depending on the API, members must provide consent for their health information to be shared. For the Provider Access API, we only share a member’s data with contracted providers who have a current treatment relationship with the member and the member has not opted out of this data sharing. For the Payer-to-Payer API, members must opt into data sharing before their data is shared with the other health plan.

Yes. Members have the right to opt in or out of sharing their health data.