Interoperability APIs
Helping connect health information across the healthcare system
CMS interoperability requirements support the secure exchange of health information between health plans, providers, patients and technology partners through application programming interfaces (APIs). These APIs help improve access to health information, support care coordination and streamline prior authorization processes.
Explore the APIs below to learn how they work, what information may be available and what they may mean for your practice.
What is an API?
Think of an API like a restaurant server. A customer places an order, the server takes the order and relays it to the kitchen, and when it's ready, delivers it back to the customer. APIs serve a similar role in healthcare, acting as a secure connection between systems to request, exchange and receive information.
- Prior Authorization API
Allows providers to check prior authorization requirements, submit requests and receive status updates and decisions without leaving their electronic health record (EHR) or electronic medical record (EMR) system. - Provider Access API
Allows providers to access patient claims, encounter, clinical and prior authorization information within their EHR or EMR workflow when they have a treatment relationship with the patient. - Payer-to-Payer Data Exchange API
Supports the exchange of health information between health plans when members change coverage or have concurrent coverage, helping promote continuity of care and reduce administrative burden. - Provider Directory API
Makes provider directory information available to patients through third-party applications. - Patient Access API
Allows third-party health applications to access a patient's claims, encounter, clinical and prior authorization information from their health plan.
Prior Authorization API
The Prior Authorization API allows you to manage prior authorization requests directly within your EHR or EMR system. Once your vendor is connected, you can check authorization requirements, review documentation needs, submit requests electronically and receive status updates as part of your existing workflow.
By making prior authorization information easier to access, the Prior Authorization API can help reduce manual work, improve visibility into requests and decisions, and simplify the prior authorization process.
What this means for you
- Prior authorization information within your workflow. Check authorization requirements, review documentation needs, submit requests and receive updates through your connected EHR or EMR system.
- Greater visibility into request status. Receive updates throughout the prior authorization process, including pending, more information needed, approved and denied statuses.
- Less manual work. Electronic access to prior authorization information can help reduce the need to navigate between multiple systems and submission channels.
Vendor connectivity
- To find out if your vendor is connected, review our list of connected EHR and EMR vendors.
- If your vendor isn't listed, contact them to learn about their plans to connect to our Prior Authorization API.
- Once connected, your vendor can show you how to use these features within your EHR or EMR system.
Frequently Asked Questions
- How does the Prior Authorization API impact the prior authorization process?
The API allows you to check authorization requirements, submit requests electronically and receive status updates within your EHR or EMR system. This can help reduce manual work and simplify your workflow.
- Can I check whether prior authorization is required before submitting a request?
Yes. The Prior Authorization API can help identify whether prior authorization is required and what documentation may be needed before you submit a request.
- What types of status updates can I receive?
You may receive updates such as pending, more information needed, approved and denied.
- Will I need to leave my EHR or EMR system to use the Prior Authorization API?
Once your vendor is connected, prior authorization information and updates can be accessed within your EHR or EMR workflow.
- Does the Prior Authorization API support all prior authorization requests?
The Prior Authorization API supports requests for medical items and services. It doesn’t support prior authorization requests for prescription drugs.
- Does the Prior Authorization API replace prior authorization requests via fax, phone or portal submissions?
No. You can continue to submit prior authorization requests through your current channels, including fax, phone and provider portals. The Prior Authorization API provides an additional submission option within your EHR or EMR system.
- Does the Prior Authorization API change prior authorization requirements?
No. Prior authorization requirements and coverage decisions remain the same. The Prior Authorization API provides an efficient way to access and exchange prior authorization information.
- What if my vendor isn’t connected?
If your vendor isn’t connected, contact them to learn about their plans to connect to our Prior Authorization API.
- Who should I contact if I have questions about a prior authorization request?
Continue to follow our current process for questions about prior authorization requests, including requests that are delayed, incomplete or require additional information.
Provider Access API
The Provider Access API allows providers to electronically access certain patient information from health plans, including claims, encounter and select clinical information, as well as prior authorization details. This information can help support treatment decisions, care coordination and value-based care activities by providing a more complete view of a patient's healthcare history.
Designed to work with connected EHR and EMR systems, the Provider Access API helps make relevant information available through the tools you already use, without requiring a separate portal.
What this means for you
- A more complete patient picture. Claims, encounter, clinical and prior authorization information can help provide additional context to support treatment decisions and care coordination.
- Seamless access to information. Patient information may be available within your connected EHR or EMR system.
- Less time spent on administrative tasks. Electronic access to patient information directly in your EHR or EMR system can help reduce the need to search across multiple systems or request information through separate channels.
- Secure information sharing. Access is limited to providers with a treatment relationship and remains subject to patient consent and applicable data-sharing regulations.
Vendor connectivity
- To find out if your vendor is connected, review our list of connected EHR and EMR vendors.
- If your vendor isn't listed, contact them to learn about their plans to connect to our Provider Access API.
- Once connected, your vendor can show you how to use these features within your EHR or EMR system.
Frequently Asked Questions
- How do I access Provider Access API data?
- Confirm your EHR or EMR vendor is connected.
- Follow your vendor's instructions for accessing claims, encounter, clinical and prior authorization information.
- Attest you have a treatment relationship with the patient.
- Is my EHR or EMR vendor connected to the Provider Access API?
You can access available patient data through your EHR or EMR system once your vendor connects to the Provider Access API. To find out if your vendor is connected, review our list of connected EHR and EMR vendors. If your vendor isn't listed, contact them to learn about their plans to connect. Once connected, your vendor can provide instructions for accessing and using these features.
- Do I need a separate portal to access Provider Access API data?
No. Once your EHR or EMR vendor connects to the Provider Access API, available data can be accessed within your existing EHR or EMR workflow. Your vendor can provide instructions for accessing and using these features.
- Am I eligible to access patient data through the Provider Access API?
You may be able to access patient data through the Provider Access API if the patient has not opted out of data sharing and you have attested to a treatment relationship with the patient.
- What does "patient attribution" mean?
Patient attribution is the process of confirming that a provider has a treatment relationship with a patient before sharing data. This helps protect patient privacy by ensuring information is shared only with providers involved in the patient's care. If you have attested to a treatment relationship but cannot access a patient's data, contact your EHR or EMR vendor for support.
- Can specialists access patient data through the Provider Access API?
Yes. Providers who have a treatment relationship with a patient may access that patient's information.
- What information is available through the Provider Access API?
Consistent with CMS requirements and applicable privacy laws, the Provider Access API provides access to information that can help support treatment decisions, care coordination and value-based care activities, including:- Claims and encounter information from the Common Payer Consumer Data Set (CPCDS), excluding financial data.
- Prior authorization information for medical items and services, including status, approval and denial dates, authorization end dates and approved items or services.
- Clinical information included in the United States Core Data for Interoperability (USCDI) data set.
- How current is the information available?
Information available through the Provider Access API is updated on an ongoing basis in accordance with CMS requirements.
- Why can't I access a patient's data?
There are several reasons patient data may not be available through the Provider Access API. A patient or their personal representative may have opted out of data sharing, or we may be unable to confirm a treatment relationship between you and the patient. If you believe you meet the requirements and still cannot access patient data, contact your EHR or EMR vendor for support.
- Can patients choose not to share their data?
Yes. Patients are included in data sharing through the Provider Access API unless they or their personal representative opt out. Patients can update their data-sharing preferences through the health plan at any time. If a patient opts out, their information will not be available through the Provider Access API, even if a treatment relationship exists. Patients may also have options to limit the sharing of certain sensitive health information.
- Does opting out affect a patient's care or benefits?
No. Opting out affects only data shared through the Provider Access API. It doesn't affect care delivery, benefits, billing or other authorized methods of sharing information.
Payer-to-Payer Data Exchange
The Payer-to-Payer Data Exchange allows health plans to securely exchange certain patient information when a patient changes coverage or has coverage through more than one health plan. With the patient's or personal representative's consent, information such as claims history, clinical information and prior authorization history may be shared between health plans to support continuity of care.
Health plans manage the exchange directly, so you do not need to initiate or manage the process. Information received through the exchange may also be available to eligible providers through the Provider Access API, subject to applicable requirements and patient consent.
What this means for you
- A more complete patient picture. Information shared between health plans may help reduce information gaps when patients change coverage or have coverage through more than one health plan.
- Better continuity of care. Historical claims, clinical information and prior authorization history can help support treatment decisions, care coordination and value-based care activities.
- Less administrative effort. Information already available through another health plan may reduce duplicate requests and follow-up activities.
- More informed decision-making. Additional health information may help support treatment planning and care coordination.
Frequently Asked Questions
- Do I need to do anything to participate in the Payer-to-Payer Data Exchange?
No. Health plans exchange information directly with one another. You do not need to initiate, manage or submit information for the exchange to occur.
- Will information from the Payer-to-Payer Data Exchange be available to me?
Information received through the Payer-to-Payer Data Exchange may also be available to providers through the Provider Access API, subject to applicable requirements and patient consent.
- How can the Payer-to-Payer Data Exchange help my practice?
When health plans can securely exchange patient information, it can help support continuity of care and reduce administrative work. Potential benefits include:- Fewer requests for duplicate records or documentation.
- Less need to collect information already available through another health plan.
- Better access to information that can support treatment decisions and care coordination.
- How does the Payer-to-Payer Data Exchange support continuity of care?
By allowing health plans to share certain patient information, the exchange can help reduce gaps in information when patients change coverage or have coverage through more than one health plan.
- Will I receive information automatically when a patient changes health plans?
Information received through the exchange may be available through the Provider Access API, subject to applicable requirements and patient consent.
- Does the Payer-to-Payer Data Exchange replace requests for medical records?
Not always. While the exchange can make certain information available electronically, additional records or documentation may still be needed in some situations.
- When does the Payer-to-Payer Data Exchange occur?
The exchange may occur when a patient changes health plans or has coverage through more than one health plan. Information is only shared when the patient or their personal representative provides consent.
- What information may be shared between health plans?
With patient or personal representative consent, health plans may exchange information such as:- Claims and encounter history, including past medical claims and visits (up to five years).
- Clinical information that supports care coordination.
- Prior authorization history for non-drug services.
- Does the Payer-to-Payer Data Exchange include information from previous health plans?
Yes. With patient consent, health plans may exchange available historical information, including claims history, clinical information and prior authorization history.
- What information is not included?
The Payer-to-Payer Data Exchange does not include:- Prescription drug prior authorization information.
- Detailed financial and cost-sharing information.
- How is information shared between health plans?
The Payer-to-Payer Data Exchange uses secure, standardized API technology required by CMS to support consistent and reliable data sharing between health plans.
- Do patients have to agree to participate?
Yes. Patients (or their personal representatives) control whether information is shared through the Payer-to-Payer Data Exchange.
- How is patient consent managed?
Patients (or their personal representatives) manage their data-sharing preferences directly with their health plan.
- What happens if a patient chooses not to share their information?
If a patient or personal representative doesn't provide consent, information won't be exchanged between health plans through the Payer-to-Payer Data Exchange.
- Can a patient change their decision later?
Yes. Patients (or their personal representatives) can update their data-sharing preferences through their health plan.
- Does a patient's decision affect their benefits or coverage?
No. A patient's choice about the Payer-to-Payer Data Exchange only affects whether information can be shared electronically between health plans. It doesn't affect eligibility, benefit or coverage.
Provider Directory API
The Provider Directory API makes current provider directory information available to third-party applications through a secure, standardized connection.
What this means for you
- Keep your information up to date. The Provider Directory API relies on provider directory information maintained by health plans. Timely updates to your demographic and practice information help ensure accurate data is available across systems and tools.
- More standardized access to provider directory information. Health plans can make up to date provider directory information (such as names, specialties, locations and network status) available through a consistent API.
- Better data accuracy with fewer manual searches. More reliable directory information supports referrals and care coordination, reducing the need for phone calls and manual searches.
- Directory information may be used in third-party applications. Some third-party applications may combine provider directory information with patient data (from the Patient Access API) to support features such as provider search, care navigation and in-network provider matching.
Frequently Asked Questions
- Will I use the Provider Directory API directly?
No. The Provider Directory API works behind the scenes to make provider directory information available to approved applications and systems that support provider searches, referrals, care coordination and other healthcare activities.
- How can the Provider Directory API benefit my practice?
Making provider directory information available across connected systems can help support referrals, provider searches, care coordination and patient access to provider information.
- How does the Provider Directory API support referrals and care coordination?
By making provider directory information available across connected systems, the Provider Directory API can help providers, healthcare organizations and patients identify the right providers, locations and network information to support referrals and care coordination.
- Who can access provider information through the API?
Access is limited to approved third-party applications and systems that meet applicable requirements for using provider directory information.
- Can patients find my information through applications that use the Provider Directory API?
Yes. Approved applications may use provider directory information to help patients locate providers, verify network participation and find practice locations and contact information.
- What provider information may be available through the Provider Directory API?
Provider directory information may include your name, specialty, practice location, contact information and network participation status.
- Does the Provider Directory API affect my network participation status?
No. The Provider Directory API doesn't determine or change your network participation status. It only makes provider directory information available to approved applications and systems.
- How current is the provider information available through the API?
Health plans regularly update the provider directory information. Keeping your information current with us helps ensure the most accurate information is available through connected applications.
- What should I do if my provider information is incorrect?
Update your information with us using the standard directory update process. Keeping your information current with us helps ensure the most accurate information is available through connected applications.
- Do I need to do anything different because of the Provider Directory API?
No. Continue managing and updating your provider information using existing processes.
- Why is current provider information important?
Current provider information helps patients, providers and healthcare organizations access provider, specialty, location, contact and network participation information when it's needed for referrals, care coordination and provider searches.
Patient Access API
The Patient Access API allows patients to give third-party health applications access to their clinical, claims and prior authorization information from their health plan.
What this means for you
- More informed and engaged patients. Bringing health information together in one place can help patients better understand their healthcare history, participate more actively in their care and support more informed conversations with their providers.
- Patient-directed information sharing. Patients control whether information is shared with applications and can manage those consents directly.
Frequently Asked Questions
- Can patients choose which applications they use?
Yes. Patients and their personal representatives can choose any app that supports health data exchange and connects to their health plan's API. We don't endorse, certify or recommend specific applications.
- Can patients stop sharing their information with an application?
Yes. Patients and their personal representatives can revoke an application's access through our consent management process in the member portal or by calling Member Services. Removing an application from a device may not stop access if authorization remains active.
- Do patients control whether their information is shared?
Yes. Patients and their personal representatives decide whether to authorize an application to access their health information and can manage or revoke those permissions at any time.
- How is patient information protected when it is shared with an application?
We use secure technology and only share data with the patient's or personal representative's permission. Once information is shared with an application, the application's privacy policy and terms of use apply.
- Can applications collect information beyond health data?
Some applications may collect additional information, such as device or location data. Patients should review the application's privacy policy to understand what information is collected and how it is used.
- Can applications share patient information with other organizations?
Each application has its own privacy and data-sharing practices. Patients who have questions about how their information is used or shared should review the application's privacy policy or contact the application directly.
- Do I need to connect to the Patient Access API?
No. The Patient Access API is used by third-party health applications that patients choose to connect to their health plan to access their health information. No action is required from your practice.
- Will I need to approve or manage a patient's connection to an application?
No. Patients and their personal representatives choose whether to connect an application to their health plan information. Providers don't initiate, manage or control these connections.
- Why might a patient ask me about information in an application?
Applications may display information from multiple healthcare sources. Patients may have questions about information related to their care or healthcare history that appears in an application.
- What should I do if a patient believes information in an application is incorrect?
Review the information in your records and follow your standard processes to correct any inaccuracies. Depending on the source of the information, the patient may also need to contact the health plan or application provider.
- Does the Patient Access API replace patient portals?
No. Patient portals remain available. The Patient Access API provides an additional way for patients to access and manage their health information through third-party applications.
- Where should I direct patients with questions about an application’s privacy or security practices?
Patients should contact the application provider directly or review the application’s privacy policy. They can also find consumer information on mobile app privacy and security on the Federal Trade Commission (FTC) website.