Skip to end of metadata
Go to start of metadata

You are viewing an old version of this page. View the current version.

Compare with Current View Page History

Version 1

Da Vinci is seeking answers to open questions and clarifications needed on the implementation and operational needs of the upcoming CMS Patient Directed API Rules. Find questions discussed by the Da Vinci Payer group and disposition including whether question was answered by CMS.  The pdf format responses are here: Set 1Set 2Set 3Set 4Set 5Set 6 (Note: questions in set 7 were combined into set 6 as questions 12-15.) 

CMS included the following statement with responses received:

These responses have been provided by the Health Informatics and Interoperability Group at CMS and are based on the Interoperability and Patient Access final rule (CMS-9115-F) published on May 1, 2020. The responses reflect current information from the final rule and do not constitute new policies nor create new requirements on the public. Please feel free to share this information with other individuals and organizations to whom it may apply.

**** CMS DISCLAIMER ****
These responses were current at the time they were provided by CMS (Date Resolved). This document was prepared as a service to the public and not intended to grant rights or impose obligations. This document may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be general information. It is not intended to take the place of either written law or regulations. We encourage readers to review the specific statutes and regulations for a full and accurate statement of their contents. Please feel free to share this information with your constituent members, organizations, or interested parties.
Individuals may send additional questions to the CMS Health Informatics and Interoperability Group (HIIG) at CMS_HealthInformaticsOffice@cms.hhs.gov.



Question

Number

Category

Keywords

QuestionDate ReceivedDisposition / AnswerDate Resolved






1001Provenance1) The definition of provenance in USCDI requires both the date/time at which the information was created as well as the organization associated with the individual that “used” the data. Payers frequently will not have knowledge of the actual date/time of creation of the specific organization that created the data (they know the organization from which it was received). 
May the payer provide a non US Core profile on the provenance resource (as specified by the Da Vinci PDex IG) to indicate that the payer is the transmitter and optionally, a second provenance resource to indicate the source of the information and method of receipt (e.g. received from xxxx organization on xxxxx via a CCDA)?
If not, should the payer
a. make a US Core provenance resource available and use a data absent reason for unknown data, or
b. exclude the provenance resource? 
23-Jun-2020Response: Appreciating the additional value the PDex IG provides for payers, and the compatibility of the PDex IG with the US Core IG, we are adding PDex as “suggested” option available to payers to meet the requirements of the rule. This information is being added to the CMS website: https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index.13-Jul-2020
1002
2) Please clarify the Payers obligation to make data (e.g. claims, encounter, clinical) available via the member access API in the following situations:
a. Payer uses separate legal entities to provide different covered plans (e.g. Medicare Advantage and Medicaid HMO). Is the payer required to make the data from all plans available to the current enrollee in one of the plans via the member API? If yes, are multiple APIs acceptable?
b. If the current enrollee in a covered plan (e.g. Medicare Advantage) was previously enrolled in the same or another covered plan (e.g. QHP in Federal Marketplace) is the payer required to make the data available from all covered plans via the member API?
c. Is the payer required to make data available from a non-covered plan (e.g. commercial coverage and not a qualified QHP) when the member is enrolled in a current covered plan (e.g. Medicare Advantage)?
d. If a member leaves the payer for five years and then returns as an enrollee in a covered plan (e.g. Medicare Advantage) is the payer required to make data available to the member via the member API going back to 1/1/2016?
e. Must enrollee authorize access to all prior coverages to the third-party app or can they restrict the data to only the current covered plan.
f. If the payer is not required to make the data from a prior enrollment (regardless of plan type) available in the member API, is the payer required to make the data available via the Payer to Payer requirement as of 1/1/2022.
23-Jun-2020Response:  (a) If the patient is a current enrollee in the Medicare Advantage plan, the payer is required to make all data they maintain for that patient as part of their enrollee record within the Medicare Advantage plan. Critical here is the definition of “maintain”. The final rule defines ‘‘maintain’’ to mean the payer has access to the data, control over the data, and authority to make the data available through the API (85 FR 25538). If the data meet this definition of maintain per the payer’s assessment and are part of an enrollee’s record, the data would need to be made available via the Patient Access API upon the patient’s request. If these maintained data are not currently in a FHIR format, these data would need to be converted to a FHIR format and shared via the Patient Access API. How a payer chooses to implement the API (one or many), is completely up to the payer.
b. Response:  As noted above, this goes back to how the payer “maintains” the data for the enrollee in their current plan.No, this is not required. Again, this goes back to how the payer “maintains” the data.
c. Response: No, this is not required. Again, this goes back to how the payer “maintains” the data.
d. Response: All payers need to make data they maintain for their current enrollees with a data of service on or after 1/1/2016 available. If an enrollee is with a plan from 1/1/2016 through 1/1/2021, leaves, and returns 1/1/2026 it would depend on how the payer maintains the data from 1/1/2016 through 1/1/2021. If these data are maintained and part of the enrollee’s record upon their return in 2026, then, yes. If the payer essentially considers the enrollee a new member in 1/1/2026 and has not maintained the previous years’ data as part of the enrollee’s current record, it would not be part of the enrollee’s record and would not be available via the Patient Access API. We note that all existing and applicable data retention requirements are assumed to be taken into account here by the payer, as appropriate.
e. Response: Starting in July 2021 when compliance with the Patient Access API is officially enforced, all specified data the payer maintains for the enrollee with a date of service on or after 1/1/2016 must be made available. If the payer maintains data other than data from the current covered plan as part of the enrollee’s record, then it would be included in what is available. Again, this goes back to how the data are maintained.
f. Response: As with the Patient Access API, the Payer-to-Payer data exchange is based on the USCDI data the payer maintains as part of the enrollee’s record. That said, if a payer receives data from a current enrollee’s former payer via a FHIR-based API under this Payer-to-Payer data exchange provision and then the enrollee asks their data be made available via the Patient Access API, the previous payer’s data should be included.
13-Jul-2020
1003
3) With respect to information received via a claim or encounter:
a. Is there any prohibition against including relevant data classes (e.g. procedure, diagnoses, medications) from a claim or encounter as part of the data the payer makes available to satisfy the requirement for clinical data where the minimum expectation is USCDI and the exchange standard is based on FHIR R4 US Core profiles? Response: There is no prohibition.
b. Is there a requirement to include such information to meet the final rule requirement for, at a minimum, clinical data represented in USCDI (e.g. Procedures, Medications)?
i. In the member access API?
ii. As part of Payer-Payer exchange at enrollee request?
Response: In both cases, if the payer maintains data elements defined as part of the USCDI version 1, these data must be shared via the appropriate API or data exchange provision.
23-Jun-2020With respect to information received via a claim or encounter:
a. Response: There is no prohibition.
b. i. & ii. Response: In both cases, if the payer maintains data elements defined as part of the USCDI version 1, these data must be shared via the appropriate API or data exchange provision.
13-Jul-2020

1004

(see also CMS Final Rule Questions and Answers log#6016)

Unstructured data (PDF, images, etc)4) Is data in PDF format considered electronic data for the purposes of meeting the requirements for enrollee access to clinical data via the member API? Same question for Payer – Payer exchange? 23-Jun-2020

Response: As noted above, if the required data elements are maintained by the payer but are not currently in a FHIR format, these data would need to be converted to a FHIR format and shared via the Patient Access API. The Payer-to-Payer data exchange does not require the use of a FHIR format starting in 2022, though we strongly encourage exchange via a FHIR API as these data will be prepared to share via this format for the Patient Access API requirements. Under the current Payer-to-Payer provision, this could be an exchange of PDF records.

Update: See Response to Question Number CMS Final Rule Questions and Answers log#4007 and CMS Final Rule Questions and Answers log#6016

13-Jul-2020

1005

(see also CMS Final Rule Questions and Answers log#6016)

Unstructured data (PDF, images, etc)5) Is data in image format (clinical images, scanned documents, etc.) considered electronic data for the purposes of meeting the requirements for enrollee access to clinical data via the API? Same question for Payer – Payer exchange? 23-Jun-2020

Response: The USCDI version 1 defines the clinical data classes and data elements that need to be included in the Patient Access API and via the Payer-to-Payer Data Exchange. Clinical images are not included in the USCDI version 1. Scanned documents should be evaluated the same way as PDF documents, as discussed in the previous question.

Update: See Response to Question Number CMS Final Rule Questions and Answers log#4007 and CMS Final Rule Questions and Answers log#6016

13-Jul-2020
2001
1. Is there a requirement for one API endpoint for all data or may a payer support multiple endpoints (e.g. one for EOB and another for USCDI data) to meet the requirements of the final rule? 
a) Is there need for a payer to provide access to covered information for more than one covered product (e.g,, CHIP, MA, Medicaid, QHP) through the same API endpoint? Does answer/guidance change depending on organizational/legal/entity structure providing products within a single payer (e.g., different organizations for CHIP, MA, Medicaid, QHP)?
b) Are there any data blocking implications if multiple patient access API endpoints are implemented as described in preceding questions?
9-Jul-2020Response: The final rule does not define the number of endpoints payers must have. A payer may support one or more endpoints to implement the final rule requirements.
The final rule also does not specify how each payer must approach making covered information for covered products available through their API or (APIs).
Generally speaking, as long as the enrollees covered by this policy are able to obtain their data in the manner required, how the API endpoints are operationalized is not a factor. For details about the HHS information blocking policy, please refer to the ONC 21st Century Cures Act final rule (see https://www.healthit.gov/curesrule/overview/about-oncs-cures-act-final-rule), and for specific questions about how those provisions apply and to whom, please send inquiries to: https://www.healthit.gov/form/healthit-feedback-form.
10-Aug-2020
2002
2. If outsourced benefit managers process claims or maintain clinical data under delegation, may they provide the Patient Access API endpoint(s) for those specific services?
a) Which organization holds responsibility for Patient Access API mandate compliance, the payer of record or the delegated benefit manager?
9-Jul-2020Response: The impacted payer is responsible for ensuring that the enrollee, upon request, receives the required data, regardless of who processes the claims or maintains the clinical data under delegation. It is up to each payer to ensure that data processed by a contractor on the payer’s behalf are available, as required, under this policy.10-Aug-2020
2003
3. The rule suggests that FHIR patient data access scope should not be recognized as part of the implementation of the Patient Access API and that the only mode is ‘all data’ available (e.g., read/*). Is this interpretation correct?  9-Jul-2020Response: Per the final rule, if a patient requests their data be made available to a third-party app via the Patient Access API, the patient is authorizing the payer to share all available data as specified in the final policy. This means all claims/encounter data and clinical data in the form of the USCDI that the payer maintains with a date of service on or after January 1, 2016, as well as formulary data. A payer is not required to provide the patient the opportunity to choose specific types or segments of this available data be shared or not shared.10-Aug-2020
2004
4. Does the concept of data that payers “maintain” require that the payer has current information available for a USCDI element (e.g., smoking status) or is the payer required to make any USCDI element available even if the data is known not to be current or to be incomplete? 9-Jul-2020Response: A payer is only required to make available the data that they maintain in their system as part of the current enrollee’s record with a date of service on or after January 1, 2016. A payer is not required to verify the current status of the USCDI data elements maintained. Per the final rule, payers are not prohibited from indicating additional information about the USCDI data, such as perceived or known status (e.g. currency or completeness) of a USCDI data element.10-Aug-2020
2005Retention policy5. Is there any requirement in the final rule that would impact a payer’s standard data retention policy? 9-Jul-2020Response: Impacted payers must make the specified data they maintain with a date of service on or after January 1, 2016 available through the Patient Access API for current enrollees. As such, this policy requires impacted payers to maintain data they have from January 1, 2016 forward for all current enrollees.10-Aug-2020
2006
6. As part of telephonic case management, payers may verbally acquire from the member information such as vital signs that are not obtained by clinical observation.
a) Is this type of information considered to be USCDI elements and therefore covered by the final rule requirement to make these data available (e.g., is member-reported data included under the rule)?
i. As part of the Patient Access API requirement?
ii. As part of Payer to Payer exchange requirement? 
9-Jul-2020Response: Though the payer did not obtain the information through direct observation, the payer is required to include the information in the Patient Access API or Payer-to-Payer data exchange if the payer maintains the data. Again, the final rule defines ‘‘maintain’’ to mean the payer has access to the data, control over the data, and authority to make the data available through the API (85 FR 25538). As such, if the data meet the above definition of maintain, the data are part of the enrollee’s record, and within the timeframe, then the data need to be included.10-Aug-2020
2007Formulary1) Does the rule require that a Formulary API includes an indicator of the status of covered drugs, tiering information, and utilization management requirements?
a) If prior authorization is required, is a single indicator (e.g., Y/N) sufficient?   
9-Jul-2020Response: The final rule requires that impacted payers, specifically MA-PD plans, Medicaid and CHIP FFS programs, Medicare managed care plans, and CHIP managed care entities make formularies or preferred drug lists available via the Patient Access API. MA organizations that offer MA-PD plans are specifically required to make available formulary data that includes covered Part D drugs, and any tiered formulary structure or utilization management procedure which pertains to those drugs (42 CFR 422.119(b)(2)(ii). Medicaid and CHIP FFS programs, Medicare managed care plans, and CHIP managed care entities are required to make information about covered outpatient drugs and updates to such information, including, where applicable, preferred drug list information through the Patient Access API (see requirements under 42 CFR 431.60(b)(4), 438.242(b)(5), 457.730(b)(4), and 42 CFR 457.1233(d)(2).
We suggest leveraging the PDex Formulary IG to meet these requirements.
a) If prior authorization is required, a single indicator of Y/N is sufficient.
10-Aug-2020
3001
1) Please verify that the Patient Access API is only required to access covered information for the covered plan covered under the rule in which the member is currently enrolled.  14-Jul-2020Response: Correct, the Patient Access API is only required, at a minimum, to make available covered information for the covered plan in which the member is currently enrolled, data which is maintained by that current plan.10-Aug-2020
3002
2) Please verify that access to information from any prior covered plan covered under the rule provided by the same payer is not required by the Patient Access API (other than via Payer to Payer exchange at member request).14-Jul-2020Response: Correct, at this time, access to information from any prior covered plan under the rule provided by the same payer is not required by the Patient Access API. The Patient Access API applies to a current enrollee’s current coverage.10-Aug-2020
3003
3) Please verify that providing access to information from prior covered plans covered under the rule provided by the same payer does not violate the final rule provisions for the Patient Access API. 14-Jul-2020Response: The Interoperability and Patient Access final rule does not prohibit payers from providing information from prior covered plans as part of patients request for information. If a payer maintains information for an enrollee from multiple lines of business and wishes to include that information, that is permissible. The final rule requirements set the minimum, but payers can include this additional information.10-Aug-2020

3004

Dental Vision4) Please verify that providing access to information from coverages (e.g., dental, vision) provided by the same payer that are not of a plan covered under the rule does not violate the final rule provisions for the Patient Access API. 14-Jul-2020

Response: All claims information, including dental and version services, that are part of an enrollee’s current plan, if that plan is impacted by the final rule, must be made available via the Patient Access API. As noted above, if the payer provided services to an enrollee previously under a different plan, the information from that previous plan is not required, though also not prohibited, to be shared. 

See also CMS Final Rule Questions and Answers log#6023

10-Aug-2020
3005
5) Please verify that the member’s use of OAuth 2.0 and Open ID Connect meet all of the requirements for an electronic signature or “written” approval for release of information that may be required by HIPAA and/or SAMHSA.14-Jul-2020Response: 42 CFR Part 2 requires specific consent to be obtained for certain types of information. That requirement is not in any way impacted by the policies in the CMS Interoperability and Patient Access final rule. All existing federal, state, and local laws that require additional consent for specific types of information are not impacted by this final rule and must be adhered to.
Regarding consent for health information not covered by regulations such as 42 CFR part 2, yes, the OAuth 2.0 authorization framework as specified in the ONC 21
st Cures Act final rule, which is adopted as part of the requirements under the CMS Interoperability and Patient Access final rule, requires the patient to formally authorize/approve for a third-party (an application) to receive data on behalf of a patient for a limited period of time, before the third-party is able to receive data using the specified API. The “authorization” part could be considered or seen as an electronic signature “process” executed by the patient with the intent to sign the data that is made accessible to the application, for the duration of time that the authorization is valid. As such, we do not believe an additional consent process is necessary for this information for this specific use.
10-Aug-2020
3006
6) Please verify that current laws, such as 42 CFR part 2 and relevant state laws restricting access to specific information (additionally protected data) must still be met to release this information in addition to the authorization by the member to release their other data to a third-party application.14-Jul-2020Response: Yes, payers must comply with current laws such as HIPAA Privacy and Security rules, relevant state laws, and 42 CFR part 2 as applicable to access and release specific information.10-Aug-2020
3007
7) Please verify that all data (e.g., claims, clinical data) not restricted by current laws (such as 42 CFR part 2 and relevant state laws) must be made available to a third-party application at the member’s request.
a. Please verify that any OAuth scope statement may only be restricted to the individual and not to the data on that individual.
b. Regarding question 7, may the payer provide any additional options regarding release of the information other than all or none? 
14-Jul-2020

Response: Yes.

Response: See response to 7b below.

Response: The final rule requires payers to make all the specified data available via the Patient Access API. Payers are not required to provide additional options to segment data or otherwise provide an opportunity to opt in or out of sharing certain FHIR resources or data elements. When a patient authorizes an app of their choice to retrieve their data from their health plan, the expectation is all available claims/encounter and clinical data is being made available. Regarding an OAuth scope statement, the inquirer may be referencing the ONC 21st Century Cures Act final rule regarding requirements for Certified EHR Technology (CEHRT). For more information on that, see 85 CFR 25741. These ONC requirements are specific to CEHRT and are not related to the CMS Interoperability and Patient Access final rule.

10-Aug-2020
3008
1. The preamble of the CMS Final Rule reads as follows: “If the patient requests their data via the Patient Access API from a payer, the payer must make available all of the data allowed per current law, such as 42 CFR part 2 and relevant state laws, including the data as specified in this final rule. We reiterate, however, that the data that are available to be shared are only to be shared at the patient’s request. If there are data elements the patient does not want to be shared, they can choose not to make the request. In addition, we note that this policy allows data to be exchanged from the payer to a third-party app of the patient’s choice for their personal use. This rule does not require any data exchange directly between or with providers.”
1. a) While the rule does not require any data exchange directly with providers, does the rule allow such an exchange (e.g., can the third-party application be a provider’s technology, such as the provider’s EHR)?
14-Jul-2020

The preamble citation and questions 1. (a,b,c,d,e) were covered in a group conversation with CMS on 10-July-2020. 

Response: A third-party application, per the final rule, is an application that the patient can use to access their personal health information. A patient does not have access to a provider’s EHR, so this would not be consistent with the requirements of the final rule.

10-Aug-2020
3009
1. The preamble of the CMS Final Rule reads as follows: “If the patient requests their data via the Patient Access API from a payer, the payer must make available all of the data allowed per current law, such as 42 CFR part 2 and relevant state laws, including the data as specified in this final rule. We reiterate, however, that the data that are available to be shared are only to be shared at the patient’s request. If there are data elements the patient does not want to be shared, they can choose not to make the request. In addition, we note that this policy allows data to be exchanged from the payer to a third-party app of the patient’s choice for their personal use. This rule does not require any data exchange directly between or with providers.”
We have four questions regarding the above quote from the final rule:
b) Does this indicate that data shared at patient’s request must include data normally requiring specific release by the patient (e.g., 42 CFR part 2 or based on specific state laws), without additional authorization by the patient, through the Patient Access API? Does this imply that the patient may only share all or nothing with a third-party application?
c) Alternatively, may the payer require/permit additional patient permission to release this additionally protected data (e.g., 42 CFR part 2 and relevant state laws) to the third-party application as per the payer’s normal policy?
d) For data, other than additionally protected information (e.g. 42 CFR part 2 and relevant state laws), may the payer provide the ability for the patient to restrict specific information based on patient preference/consent?
e) May the patient authorize the payer to only allow a specific third-party application to receive a specific sub-set of their information (e.g. allow access to claims data but not clinical data)?
14-Jul-2020

The preamble citation and questions 1. (a,b,c,d,e) were covered in a group conversation with CMS on 10-July-2020. 

Response (1.b.): Current law must be adhered to – such as 42 CFR part 2 and relevant state law. As stated in the final rule, “the policies finalized in this regulation do not change any payer or provider’s obligations to abide by existing federal and state regulations and law, including 42 CFR part 2, which governs certain substance use disorder records, which are some of the most sensitive health information. We note, however, that the patient can direct the entity to transfer this sensitive data upon their designation of a recipient, or may provide consent or authorization for the transfer, as applicable” (85 FR 25538).

Response (1.c): See response above (1.b) (3009).

Response (1.d): See response to question 7b above (CMS Final Rule Questions and Answers log#3007).

Response (1.e): See response to question 7b above (CMS Final Rule Questions and Answers log#3007).

10-Aug-2020
4001Consent1. Is the Patient Access API intended to support consent for and access by (e.g., creating identities for) the following?
a. The member
b. A member’s “representative” (as defined in the Rule) (patient advocate)
c. parent access to dependent children’s data
d. spouse access to member’s data
e. PCP access to member’s data, etc.
f. Are third parties granted delegated access without bearing to the relationship between member and payer, rather relationship between member and the patient?
16-Jul-2020Consensus was not to send this question. 16-July-2020
4002General1. The final rule requires that we share information we 'maintain.' Information obtained via CMS Blue Button includes specific consent and release requirements. Does final rule supersede the Blue Button consent model and are we required to share this information as part of the Patient Access API? 16-Jul-2020Response: If this question is being asked from the perspective of a payer, this could be a unique situation, as Blue Button generally does not share information with payers. The Medicare Blue Button enables beneficiaries to access their Medicare Parts A, B and D claims and encounter data, and share that electronic information through an API with approved applications, services and research programs they select.10-Aug-2020
4003General2. We are assuming that the FHIR access scope, given to the apps, is patient/*.read. This is particularly important in terms of how we will support access to data for a minor dependent or for access by a personal representative to the person/people they represent. The implication is that the consent flow will require the user to select the person who’s data they are connecting the app to (it could be their own, if a member, a minor dependent or a person that they are a personal representatives for).  The alternative (some sort of new user scope for multiple patients) does not look to have any convention that can be adopted, without complicating the work for apps. 16-Jul-2020Response: In the Interoperability and Patient Access final rule, we reiterated that data sharing is already effectively occurring; the API is a new way to make the data available. We also said that the current regulation does not change existing privacy relationships between minors and parents. In most health plans, the policy holder has access to the claims and other information for other members covered by the policy, unless there is a privacy provision in place. And we referenced the HIPAA Privacy Rule at 45 FR 164.522, which says that individuals have a right to request restrictions on how a covered entity will use and disclose protected health information. The final rule does not change any requirements under federal, state, local, or tribal law. Please see 85 FR 25547 for a more complete discussion of privacy and access as it relates to an enrollment group.10-Aug-2020
4004General3. State Medicaids and others have asked that if they have “outsourced” to other entities certain benefits management and claims processing (e.g., behavioral health, pharmacy, dental), does the API requirement still apply to them (the state agency) or can Medicaid direct the member to the outsourced entity and expect the outsourced entity (e.g., benefit manger) will accept the responsibility for compliance? 16-Jul-2020Response: If an organization impacted by the Interoperability and Patient Access final rule, including State Medicaid programs, has outsourced certain benefits management and claims
processing, the requirements of the final rule still apply to them. For example, a Medicaid beneficiary should be able to find an app of their choice and authorize that app to retrieve their data via the Patient Access API. The identity of the business associate, outsourced entity, or benefit manager is not relevant. It is the responsibility of the State to ensure if a beneficiary covered by them is able to request the specified data. See 85 FR 25532 for further discussion on this point.
10-Aug-2020
4005ADT Sharing1. Please confirm that hospitals covered under the final rule that meet the ADT requirement as defined at 45 CFR 170.205(d)(2) (HL7 2.5.1) may exchange the designated minimum data regarding an admission, discharge or transfer by any electronic method and not just by using HL7 V2 messaging.  16-Jul-2020Response: The policy for the Patient Event Notification CoP requirement is limited to those hospitals and CAHs that utilize an electronic medical record system or other electronic administrative system with the capacity to generate information for electronic patient event notifications. The standard is defined 45 CFR 170.205(d)(2). It is correct that this requirement does not require the use of a specific standard to share the electronic notification. We did not propose, and thus did not finalize, a specific format or standard for the patient event notification that a hospital would be required to send under the proposed CoP. Thus, hospitals would be allowed to transmit patient event notifications using other standards, such as the CCDA or via a FHIR-based API (see 85 FR 25596 through 25597).10-Aug-2020
4006ADT Sharing2. Please confirm that exchange of ADT using Da Vinci Alerts IG would meet notifications going to approved care team members (e.g., primary care, payer)? 16-Jul-2020Response: The policy for the Patient Event Notification CoP requirement is limited to those hospitals and CAHs that utilize an electronic medical record system or other electronic administrative system with the capacity to generate information for electronic patient event notifications. The standard is defined 45 CFR 170.205(d)(2). It is correct that this requirement does not require the use of a specific standard to share the electronic notification. We did not propose, and thus did not finalize, a specific format or standard for the patient event notification that a hospital would be required to send under the proposed CoP. Thus, hospitals would be allowed to transmit patient event notifications using other standards, such as the CCDA or via a FHIR-based API (see 85 FR 25596 through 25597).10-Aug-2020
Unstructured data (PDF, images, etc)If data covered by USCDI is in PDF or image format, does making it available via the Document Reference resource meet the requirement for the Patient Access API? 16-Jul-2020

Response: We are continuing to evaluate this question. (10-Aug-2020)

Email response from Denise St. Clair to Ryan Howells following WEDI Panel discussion on 20-Oct-2020: 

As you know, a number of payers reached out to ask how to address situations where a payer maintains unstructured data such as a large PDF or a scan of a fax that may or may not include data elements in the USCDI. We note that payers should focus on the USCDI data that can be identified at the data element level – data that a payer maintains as part of an enrollee's record as a discrete data element that the payer can then map to FHIR and make available via the Patient Access API. We strongly encourage payers to work to make as much data available to patients via the Patient Access API as possible to ensure patients have access to their data in a way that will be most valuable and meaningful to them, but we are not asking payers to manually go through large files that cannot be parsed into data elements efficiently for the purposes of this API. 

26-Oct-2020
4008Patient Access API, Information Blocking, and Organization Type1. Is the payer a covered actor with regard to data blocking? If so,
a. Do the civil monetary penalties apply to the payer?
b. Which exchanges are considered part of the evaluation of data blocking?
1. to the enrollee’s authorized third-party application (EOB, USCDI)
2. payer to payer as directed by the enrollee or past enrollee
3. other requests for data (e.g., from providers)
16-Jul-2020Response: Information Blocking is beyond the purview of the CMS Interoperability and Patient Access final rule. For questions related to information blocking, refer to the Office of the
National Coordinator’s webpage and InfoGraphic which provides a summary:
https://www.healthit.gov/topic/information-blocking. For additional assistance on the ONC rule, send questions to the ONC feedback form: https://www.healthit.gov/form/healthit-feedback-form
10-Aug-2020
4009Patient Access API, Information Blocking, and Organization Type2. If a single payer plays multiple roles in the industry (such as providing a covered insurance product, having providers that deliver care, owning part or all of an HIE, developing covered applications, etc.),
a. Do the CMS rules only apply to the payer role?
b. If other roles fall under the actor descriptions for the ONC rule, do the ONC Final Rule requirements only apply to that specific role?
c. Does the answer for the questions above depend on the legal structures of the entities delivering these roles? 
16-Jul-2020

Response: The CMS Interoperability and Patient Access final rule requirements apply to the
payers indicated in the final rule. The data that these payers must make available depends on
how the payer maintains the data.

Response: Questions specific to obligations under the ONC 21st Century Cures Act final rule
should be directed to the Office of the National Coordinator at For additional assistance on the
ONC rule, send questions to the ONC feedback form: https://www.healthit.gov/form/healthitfeedback-form

No response was provided for question 2c. 

10-Aug-2020
4010Patient Access API, Information Blocking, and Organization Type3. Can clarification of the definitions of HIE and HIN be provided for compliance and operations?16-Jul-2020Response: Questions specific to obligations under the ONC 21st Century Cures Act final rule
should be directed to the Office of the National Coordinator at For additional assistance on the
ONC rule, send questions to the ONC feedback form: https://www.healthit.gov/form/healthitfeedback-form
10-Aug-2020
4011Patient Access API, Information Blocking, and Organization Type4. If a payer chooses not to implement a suggested IG (such as CARIN BB or PDex Plan Net) and subsequently adopts their own proprietary IG, does this constitute data blocking? 16-Jul-2020ANSWER: The CMS Interoperability and Patient Access final rule does not require the use of
any specific Implementation Guides. That said, the implementation guides suggested provide
information payers can use to meet the requirements of the policies finalized in the rule without
having to develop an approach independently, saving time and resources. In addition, the
reference implementations made available for this IG allow payers to see the APIs in action and
support testing and development. We note that the rule does require payers to make
documentation about their API publicly and freely available as not to inhibit a third-party app
from accessing the API at an enrollee’s request. Ultimately, we do strongly encourage payers to
consider using the suggested IGs.
For questions related to information blocking and impacted organizations, refer to the Office of
the National Coordinator’s webpage and InfoGraphic which provides a summary:
https://www.healthit.gov/topic/information-blocking.
10-Aug-2020
4012Patient Access API, Information Blocking, and Organization Type5. If an application vendor (such as Apple Healthkit) adopts the CARIN IG as the method for patient administrative data intake, as recommended by CMS, does every payer need to accommodate that application vendor’s decision to use the CARIN IG? 16-Jul-2020Response: The CMS Interoperability and Patient Access final rule requires impacted payers to
make certain information available via a FHIR-based API. Third-party vendors can leverage
these types of data and offer their apps to patients. A compliant payer API will have the
necessary data available in the specified FHIR format, and the payer will have the required API
documentation publicly available. This will permit third-party apps to accommodate patient
requests to retrieve their data from impacted payers. The final rule does not include requirements
for third-party vendors.
10-Aug-2020
5001

Payer to Payer

Retention Policy

1. Are there any conditions under which the January 1, 2016 date is not applicable:
1.1. If normal payer retention policies make data subsequent to January 1, 2016 not maintained by CMS definition?
1.2. If data is received from another payer at enrollee request and exceeds the current payer’s retention policy? 
21-Jul-2020Response: The Interoperability and Patient Access final rule requires impacted payers to make the specified data they maintain with a date of service on or after January 1, 2016 available per patient request. The final rule defines ‘‘maintain’’ to mean the payer has access to the data, control over the data, and authority to make the data available through the API (85 FR 25538). We encourage each payer to look at how they maintain the data as part of the patient record to determine whether it fits within the criteria.10-Aug-2020
5002Payer to Payer2. If the current payer receives information from a prior payer at member direction, is the current payer required to maintain the information in the format(s) it was received and exchange it with a subsequent payer in the same format(s)?21-Jul-2020Response: Yes. An impacted payer is only required to maintain and send data received under this payer-to-payer data exchange requirement in the electronic form and format it was received. In this way, a payer would not be asked to receive paper records from another payer under this policy and then in turn share those paper records with another payer in the future at the patient’s direction. If the payer received an enrollee’s information via an API, the payer must share it via an API if the payer they are sending it to has the capacity to receive it (85 FR 25567).10-Aug-2020
5003Payer to Payer3. If a current payer translates information received from a prior payer into FHIR resources and makes those FHIR resources available to a subsequent payer, does this meet the requirement of the rule? 21-Jul-2020Response: A payer is not required to translate information received under this payer-to-payer data exchange requirement to FHIR. However, a payer is not prohibited from doing so.10-Aug-2020
5004Payer to Payer4. Is the current payer allowed to exchange the data received from a prior payer in the original format and any translation of any part of those data into FHIR to a subsequent payer?21-Jul-2020Response: Yes. The Interoperability and Patient Access final rule only requires payers to receive and maintain data in the form and format it was received under the payer-payer exchange requirement. There is no prohibition on exchanging the data received from a prior payer in a FHIR format. We do encourage payers to consider sending and receiving these data via an API, and we did note in the final rule that we may consider for future rulemaking an API-based payer-to-payer data exchange (85 FR 25567).10-Aug-2020
5005
5. If a covered plan maintains data derived from clinical or claims data that meets the USCDI definitions, but is solely generated by the payer, do these data need to be made available via the Patient Access API and exchanged via the Payer-to-Payer requirement?21-Jul-2020Response: If a covered plan maintains USCDI data as part of an enrollee’s record, , those data should be made available via the Patient Access API and payer-to-payer requirements.10-Aug-2020
5006Payer to Payer6. In the patient-directed exchange between a prior payer and the designated recipient payer, can the “send data requirement” be met by giving the designed recipient payer access to the API for clinical data (USCDI) that is used for enrollee designated third-party applications?
a) If data has been received from a prior payer in a format other than FHIR, can the data be exchange by a separate method or made available through a FHIR DocumentReference resource?
b) If the receiving payer utilizes the FHIR API to receive the data is the payer required to make the same information available to the enrollee (assuming they are a current enrollee of the receiving payer in a covered product) along with other USCDI information maintained by the payer.
21-Jul-2020Response: The Interoperability and Patient Access final rule does not specify the means by which payers conduct the exchange of electronic information between payers under the Payer-to-Payer Data Exchange. As noted above, we do encourage payers to consider leveraging an API for this data exchange. As the method of electronic data exchange is not specified, there are no specific requirements around FHIR resources. We do encourage payers to consider using those FHIR resources that will make the data most valuable to other payers and ultimately to patients over time.
a) If data has been received from a prior payer in a format other than FHIR, the final rule requires payers to incorporate data they receive from another payer into their enrollees record. However, a payer is only required to send data received under the payer-to-payer data exchange in the electronic form and format it was received (85 FR 25567).
b) If the receiving payer utilizes the FHIR API to receive data from another payer, they must incorporate the data they receive into the enrollee’s record. As such, the payer now maintains that data, and must provide it to the enrollee, along with the other USCDI data it has and maintains, should the payer request their data via a third-party up under the Patient Access API requirement.
The final rule obligates the payer to send data received from another payer in the electronic form and format it was received, and to send the USCDI data they maintain. The Payer-to-Payer Data Exchange must take place with the approval and at the request of the enrollee.
22-July-2020
5007
7. Will CMS FFS participate in the exchanges defined by the CMS final rule?
a) Can Medicare FFS receive data from another payer at the direction of the enrollee?
b) Will CMS provide information received from another payer at the direction of the enrollee, along with any USCDI maintained by CMS, to another payer at the direction of the beneficiary? Will this capability exist for 5 years after the beneficiary leaves Medicare FFS?
21-Jul-2020Response: The Medicare Fee-for-Service (FFS) program, although not required under the Interoperability and Patient Access final rule, is developing the capability to receive data from other payers at the direction of the enrollee as part of its modernization initiative. Generally, Medicare FFS is working toward meeting the requirements as stated in the final rule for the benefit of its beneficiary population even though not required to do so.10-Aug-2020
6001

Do payers need to support requests for all data on an enrolled member in a covered plan at any time in the Patient Access API or can we only make new data available once the application has requested and received all data back to 1/1/2016?

28-Jul-2020The rule does not limit a payer’s obligation to a delta file of new data.09-Nov-2020
6002

Patient Access API

Payer-to-Payer

Information Blocking

If information is exchanged from a prior payer to the current payer at member direction, and the information is not in the Patient Access API format, it is our understanding that the current payer does not need to make this information available via the Patient Access API. Is this correct and is this not considered data blocking?28-Jul-2020Per the final rule, data received via the payer-to-payer data exchange only need to be made available to share in the electronic form and format they were received from another payer (see 85 FR 25567). As a result, if a payer receives data from a current enrollee’s former payer via a FHIR-based API under this payer-to-payer data exchange provision, and then the enrollee asks that their data be made available via the Patient Access API, the previous payer’s data should be included in the data made available via the Patient Access API. It is not information blocking to only make available those data specified in the regulation as available via the API. However, all existing federal, state, and local laws apply, and if the patient requests their record outside of the Patient Access API, then a payer must accommodate existing law governing the patient’s request.09-Nov-2020
6003

Patient Access API

Payer-to-Payer

Information Blocking

If information is exchanged from a prior payer to the current payer at member direction, and the information is in the format used by the Patient Access API, is the current payer required to make this prior payer’s data for the member available via the Patient Access API? If it is optional and the current payer elects to not include the information in the Patient Access API is this considered data blocking?28-Jul-2020If a payer receives data from a current enrollee’s former payer via a FHIR-based API under the payer-to-payer data exchange provision, and then the enrollee asks that their data be made available via the Patient Access API, the previous payer’s data should be included in the data made available via the Patient Access API (see 85 FR 25567). As these data would need to be shared, there are no implications for information blocking.09-Nov-2020
6004Duplicate dataIf a payer has the same information available from multiple sources (claims, CCD, ORU) for the same event (e.g. procedure) or for the same element from multiple events (e.g. diagnosis) and the payer makes the information available once for each occurrence does that meet the requirements of the rule?28-Jul-2020All claims data with a date of service on or after January 1, 2016 must be made available via the Patient Access API. For data elements included in the USCDI version 1, payers must make available those data they maintain with a date of service on or after January 1, 2016, as well. If the same data element is included in the enrollee’s record from multiple sources for the same event, that information only needs to be mapped to FHIR and made available via the Patient Access API once. This would ensure this single event is represented, but duplicate information for that single event is not included. As other data elements may remain constant for some time and/or change over time, payers should look at the data they maintain and ensure that information relevant to the patient’s care and treatment over time is accurately represented – in this way, it may not be appropriate to include a single data element only once across multiple events.09-Nov-2020
6005
If an EHR charges to “register” an application used by a payer to obtain information required for permitted purposes (e.g. payment, operations, care coordination), does this constitute information blocking? (currently certain EHR vendors charge over $20,000 and an annual maintenance or usage fees)28-Jul-2020For questions related to vendors and information blocking, contact ONC via the ONC feedback form: https://www.healthit.gov/form/healthit-feedback-form09-Nov-2020
6006

Security

Information Blocking

Are there required metrics for information security (e.g., levels of denial of service attacks, number of inquiries per unit time, etc.) that plans can employ to appropriately revoke access to third parties and avoid risk of information blocking violations?28-Jul-2020Per the final rule, payers may only deny or discontinue any third-party application’s connection to their API if the payer reasonably determines, consistent with its security analysis under 45 CFR part 164 subpart C, that allowing an application to connect or remain connected to the API would present an unacceptable level of risk to the security of protected health information on the payer’s systems or in transit in instances in which the individual did not tell the payer to disregard in-transit risk. When access has been denied or discontinued due to security concerns, we encourage payers and third parties to work together to address the concerns if and as possible to best serve patients. We are not able to set a specific time period or process for this as it is beyond our authority, however, we do note that the HIPAA Privacy Rule requires access to be provided to the individual in a timely manner (see 85 FR 25548).
The criteria and process for assessing unacceptable risk to a payer’s system are part of the payer’s responsibilities under the HIPAA Security Rule. The HIPAA Security Rule requires a covered entity to perform risk analysis as part of its security management processes (45 CFR 164.308(a)1)(ii)(A)). HHS makes a number of tools available to assess risk (For more information, see https://
www.hhs.gov/hipaa/for-professionals/security/index.html). Additional tools are available through the National Institute of Standards and Technology (NIST) (see https://csrc.nist.gov/publications/detail/nistir/8062/final).
09-Nov-2020
6007

Processing

Adjudication

1 business day

What is the definition of “processing” claims and encounter data to be made available “no later than one business day” in the patient access API? Does the period start on:
7.1. receipt of the claim by payer or contracted claims processor
7.2. after adjudication (partial or full)
7.3. Is the answer impacted if the payer only processes claims periodically (e.g. once a week)?
28-Jul-2020We finalized that payers make available through the Patient Access API, no later than one (1) business day after the information is received: (1) adjudicated claims, including claims data for payment decisions that may be appealed, were appealed, or are in the process of appeal, and (2) encounter data. We reiterate that this is one (1) business day after the claim is adjudicated or encounter data are received. This allows for potential delays in adjudication or delays in providers submitting their encounter data. It does not require payers and providers to change their contractual relationships or current processes for receipt, though we strongly encourage payers and providers to work together to make patient data available in as timely a manner as possible (see 85 FR 25535).09-Nov-2020
60081 business dayWhat is the definition of next business day? If information is received between 12:01 AM and 11:59 PM on a business day does "the next business day" end at 11:59 PM the next business day (all times assumed local to site where processing occurs)?28-Jul-2020Generally, CMS considers receipt by close of business (generally between 4 and 5pm) to be within the business day. After close of business, would not be considered receipt until the start of the next business day. Therefore, if a claim is adjudicated and available to the payer to share starting at 6pm on a Monday. The one business day clock would not start until Tuesday start of business. And, the claim would not have to be made available to the patient until Wednesday, the earliest.09-Nov-2020
6009

Provider Directory

Security

Although the payer’s provider directory API may not require a member account for secure access, is service level security permissible with the provider directory API?
9.1. Can payers enforce service level security (to prevent denial of service attacks, exposure to bad actors, SQL injection, etc.)?
9.2. Is there any restriction on putting basic best practices in place to make the Provider Directory API accessible and prevent attacks on its availability?
28-Jul-2020The Provider Directory API endpoint must be made publicly accessible. Specifically, the rule requires payers make the Provider Directory API accessible via a public-facing digital endpoint on their website to ensure public discovery and access. Payers must exclude the security protocols related to user authentication and authorization (required for the Patient Access API) and any other protocols that restrict the availability of this information to anyone wishing to access it. As this is not PHI, and generally publicly available information at this time, restrictions are not permitted (see 85 FR 25560 through 25564).
You can put this information behind an initial firewall in order to protect against things like a denial of service attack, much as you would currently protect data available via your website, but otherwise this must be a truly public and unrestricted digital endpoint.
09-Nov-2020
6010

USCDI

risk adjustment

quality improvement

utilization management

condition

diagnosis

Does data collected by payers for risk adjustment, quality improvement, or utilization management that is also considered part of USCDI, e.g., conditions/diagnoses, need to be shared as part of USCDI via the Patient Access API? Or only is it was obtained through clinical data sources such as CDA documents and ORU result messages?28-Jul-2020All USCDI data that the payers maintain as part of the enrollee’s record are to be made available via the Patient Access API. The final rule defines ‘‘maintain’’ to mean the payer has access to the data, control over the data, and authority to make the data available through the API (85 FR 25538). The rule does not limit the available data by how the data are being used or the purpose for which they were originally received. If the data are currently maintained, they must be made available via the Patient Access API.09-Nov-2020
6011

partner

contract

maintain

If a payer uses a partner to administer specific benefits (e.g. drug benefit) and the partner collects clinical information as part of the normal process (e.g. allergy intolerances gathered from patients before dispensing medications), is this data in the scope of clinical data maintained by a payer and must be made accessible through the Patient access API?30-Jul-2020This goes back to the definition of ‘‘maintain’’. It is up to each payer to assess your relationship with the partner to understand if these data would be within your access, control, and authority to share. A contracted relationship where a partner is collecting and maintaining data on behalf of the payer would generally qualify as data “maintained” by the payer.09-Nov-2020
6012

Patient Access API

Security

OAuth

OpenID

SMART on FHIR

authentication

If a covered payer requires an application that wishes to access the Patient Access API to meet specific industry standard requirements for secure access to confidential information in addition to compliance with OAuth 2.0 and OpenID Connect to ensure that an application will not present a risk to the payer systems, does this violate the CMS final rule?06-Aug-2020Additional security, such as the use of multifactor authentication, for instance, is supported by the required standards. SMART on FHIR, and specifically the OAuth 2.0 standard HHS has finalized provides robust support for multifactor authentication. Such additional security is not prohibited via the technology or the specifications in the rule. As noted in the final rule, by requiring that payers subject to our Patient Access API requirement use an API that is conformant with 45 CFR 170.215, where HHS has finalized the SMART IG, we are supporting the use of multifactor authentication (85 FR 25545).09-Nov-2020

Patient Access API

Security

OAuth

token

representative

Payers require, from a security and audit perspective, that the authorized third-party application must use the OAuth token issued by the payer for a specific individual that has been granted access to the information. This token cannot be used by the application to allow another individual to “act on behalf of the member”. By this we mean that access by an “authorized representatives” cannot be granted the ability to use another individual’s (e.g. the member’s) token. The payers will enforce the requirement that the token is issued and may only be used for a single application and individual context. This would be considered a security violation and the basis for denying the application’s access to the API. Does this violate any portion of the CMS final rule regarding access to the Patient Access API.
We note that OAuth is a delegation protocol to act on the patient’s behalf. And, we note that per the final rule, when we discuss patients, we acknowledge a patient’s personal representative. According to the HIPAA privacy regulations at 45 CFR 164.502(g), a personal representative is someone authorized under state or other applicable law to act on behalf of the individual in making health care related decisions (such as a parent, guardian, or person with a medical power of attorney). See OCR guidance regarding personal representatives at
https://www.hhs.gov/hipaa/forprofessionals/faq/2069/under-hipaa-when-can-afamily-member/index.html).
Policies in this final rule that require a patient’s action could be addressed by a patient’s personal representative (see 85 FR 25514). In this way, a token would have to be granted to the patient’s personal representative on the patient’s behalf, just as the payer would have to provide access to a patient’s health information to their personal representative if requested on the patient’s behalf today.
09-Nov-2020
6014

consent

credential

token

authorization

authentication

identity

We assume that the payer’s API and supporting consent model govern right of access and issue a specific credential (such as a token) for each beneficiary and authorized individual as opposed to the application handing such credential management?06-Aug-2020The expectation is that the payer will maintain a protected resource server, which will be looking for a token from the app to provide the role and access rights of the enrollee. If the token is not valid, the protected resource server should direct the enrollee request to the authorization server. The authorization server can establish the identity of the enrollee either itself or by interacting with a separate identity server. Either way, a screen (or series of screens, if necessary) can be displayed where the patient provides the necessary credentials (such as user name and password, multi-factor authentication, retina scan, etc.) to establish their identity. For the best enrollee experience, this would ideally be done within the client web or mobile app itself and not require the enrollee to manually visit another portal themselves.
When the authorization server is satisfied with the identity and access request, an access token is generated representing the role and access rights for the enrollee, which can be used by the app on subsequent requests to the protected resource server. A separate identity token can also be generated to allow systems to get more information about the identity of the enrollee, if needed (e.g. address, phone number, etc.).
The authorization server is an integral part of the API. When the request arrives at the API from the third-party app, if there is a token, and it is valid, then the data exchange is authorized. If the token is not valid -- for instance if it is expired or not for the specific information being requested, etc. -- an authorization error will be returned. This is all part of the API, done through a series of forwarding requests.
09-Nov-2020
6015representativeConfirm that within the context of the rule, a representative is not distinguished or managed based upon their relationship with the beneficiary and are all handled the same? An example would be that a representative may be a spouse or may be PCP, but for the purposes of representation, the payer doesn’t change API behavior based upon the relationship. A representative is a representative and is treated the same regardless of the relationship between the representative and the beneficiary OR the relationship between the representative and the payer (other than for issuance of the token).06-Aug-2020Please see the response to question #13 above. For the Patient Access API, the request would have to be initiated by the patient or their personal representative. (CMS Final Rule Questions and Answers log#6013)09-Nov-2020

6016

unstructured data

pdf

discrete data element

parse

DocumentReference

There is a substantial difference in the implementation effort and risk (e.g. errors, completeness, clinical context) of taking unstructured data (e.g., PDF, jpeg, or other unstructured formats) and converting the USCDI data elements contained in it to FHIR resources versus using the FHIR
DocumentReference resource to make the unstructured data available via the Patient Access API. Operational concerns of payers include the following:
a. Non-standard, inconsistent conversion of unstructured data to FHIR by each payer creates risk in the interpretation of the information
b. The NLP method of conversion of unstructured data will differ by vendor, and results in variability of the FHIR content
c. The Provenance of the FHIR output in Payer-to-Payer, to document that the source was a PDF conversion will be a challenge to the receiving payer if the sending payer does not accurately and consistently document and identify the source as originally a PDF.
Covered payers need immediate guidance from CMS indicating if using DocumentReference to exchange unstructured data meets the requirements of the final rule with regard to clinical data received by the payer as unstructured data.
25-Aug-2020Regarding unstructured data such as a large PDF or a scan of a fax that may or may not include data elements in the USCDI, we note that payers should focus on the USCDI data that can be identified at the data element level – data that a payer maintains as part of an enrollee's record as a discrete data element that the payer can then map to FHIR and make available via the Patient Access API. We strongly encourage payers to work to make as much data available to patients via the Patient Access API as possible to ensure patients have access to their data in a way that will be most valuable and meaningful to them, but we are not asking payers to manually go through large files that cannot be parsed into data elements efficiently for the purposes of this API. And, we are not asking payers to include these large files in the data available via the API.09-Nov-2020
6017
While the directory data for a covered payer is required to be openly available, the formulary data for the same covered payers (where applicable) is required to be part of the Patient Access API. If formulary is included as part of the Patient Access API, it will be subject to the same authentication and authorization process as the remainder of the members claims and clinical data. The implementation guide cited on the CMS web site (PDex Formulary) does not provide for plan member authentication and authorization.
a. Is the requirement to present formulary information only in the context of the member?
b. If so, this information will not be available for consumers to compare drug coverage by different drug benefit plans. Is this the intent of the final rule?
c. If not, please provide clarity on the expectation for access to formulary?
d. If a covered payer chooses to make the formulary only openly available (e.g. not part of the Patient Access API) is this considered compliant with the final rule?
25-Aug-2020The rule does not prohibit making formulary data openly available, just like the Provider Directory data. There is no prohibition in the rule to making the formulary endpoint publicly accessible. This would support implementing the “Shopping for Health Plans” use case detailed in this implementation guide (IG). Supporting this use case is not required by the rule, but it not prohibited.
The final rule does require that the formulary data specific to the patient in question be made available via the Patient Access API. As such, access to the formulary service when integrated with protected health information (PHI) or personally identifiable information (PII) as part of the Patient Access API shall be protected through an authorized, authenticated transaction. Additional information about this use case has been added to the PDex Formulary IG.
09-Nov-2020
6018
If a member directs a plan to share information with another plan and the member chooses to do so in such a manner that the same information is provided by more than one prior plan (e.g. Plan B has Plan A’s information from a prior request to share and the member directs both A and B to share the information with plan C),
a. Is it the responsibility of each plan to indicate if the information comes from a prior plan?
b. Is it the responsibility of the receiving plan (e.g. Plan C) to identify and eliminate duplicate data?
c. If the information is in Patient Access API format, is it acceptable to present all of the received data (from both Payer A and Payer B) via the Patient Access API with any duplication of data included?
25-Aug-2020If a payer gets a request from a member to share data with another payer, the payer’s only obligation is to make the required data available to the designated payer. Payers have the ability to indicate the provenance of the information they are sending. Receiving plans are not required to deduplicate data they have received from other payers. If a payer receives information under the payer-to-payer data exchange via an API, and subsequently shares those data via the Patient Access API, the payer is again only obligated to send the required data they maintain. They are not required to deduplicate or otherwise review or validate data they receive from another payer.09-Nov-2020
6019
With respect to the term adjudication in final rule, is it CMS’s intent that this process is complete (e.g. starts the 1 business day clock) when the claim processing is finished or when the provider payment process is completed. There may be several days of delay between the processing of a claim and the payment to the provider, during which the provider may question the reimbursement and adjustments may be made that need to be reflected in the EOB.
a. Does the 1 business day clock start on completion of claims processing or on completion of initial payment to the provider?
25-Aug-2020By “adjudication,” we mean determination of whether a given claim is entitled to reimbursement pursuant to the terms and conditions of a particular plan, and the amount payable to and by relevant parties. We appreciate that adjudication is a process, however. Because it is a process, and that process varies by payer, adjudication is not defined as always pre- or post- payment. Ultimately, a payer needs to assess their system and their process, and in good faith work to get patients information timely. If edits were still pending on a claim even if the claim was in approved status, for instance, one could argue that claim is not fully adjudicated as the impending edits could change the amount to be paid by whom based on the given payer’s process.09-Nov-2020
6020
How long does a covered payer have to register a third-party application so that a member may use the application to access the Patient Access API?
The rule does not specify a time period, but we do point to the ONC 21st Century Cures Act final rule for guidance on this. In alignment with requirements in this rule, we suggest tokens be valid for at least 3 months (see 85 FR 25746).09-Nov-2020
6021
During the September HL7 Connectathon several questions were raised regarding the open access to a covered payer’s provider directory. We acknowledge and support the goal of not requiring additional actions/steps by the consumer/member in accessing the provider directory information. However, several questions were raised regarding open access and application registration:
a. If a covered plan publishes their provider directory as a PlanNet compliant collection of resources (e.g. as a bundle or in ndjson format) on an openly accessible site, would an API supporting retrieval of such files (e.g., GET /path/to/directory.ndjson) satisfy CMS requirements for open access?
b. From an API security and performance perspective, all API consumers (apps, not users) should be known and use an API key (or other auth mechanism) so the covered knows the identity of the applications/developers (this is standard industry approach today). Several mechanisms are widely and commonly used by organizations offering public access APIs; for example using a public anonymous token, or a clientID/Secret combination. This approach would not make it any harder for an individual to use the API, nor require individuals to identify themselves. However, it will ensure the service can properly track the application being used and protects the API from attacks (which would now be traceable to the registered application). Are these practices within scope of the rule to provide API access to covered data?

The final rule requires payers make the Provider Directory API accessible via a public-facing digital endpoint on their website to ensure public discovery and access. Payers must exclude the security protocols related to user authentication and authorization (required for the Patient Access API) and any other protocols that restrict the availability of this information to anyone wishing to access it. As this is not PHI, and currently publicly available information, restrictions were not included.
You can put this information behind an initial firewall in order to protect against things like a denial of service attack, much as you would currently protect data available via your website, but otherwise this must be a truly public and unrestricted digital endpoint.
We strongly suggest the use of the PlanNet IG to meet this requirement. And, in August, through the Medicaid State Directors letter, the use of the PlanNet IG was required for state Medicaid agencies seeking to access the enhanced FFP (see https://www.medicaid.gov/federal-policy-guidance/downloads/sho20003.pdf).
09-Nov-2020
6022
Can EHR vendors prevent payers from using a SMART on FHIR app appropriately registered with an EHR vendor for a permitted purpose?
The CMS Interoperability and Patient Access final rule does not regulate EHR vendors. For additional information about requirements for EHR vendors, we suggest reviewing the ONC 21st Century Cures Act final rule. More information is available here: https://www.healthit.gov/curesrule/.09-Nov-2020

Additional information on Dental and Vision claims:

We do note that although the rule does not exclude vision and dental claims, we appreciate that the CARIN IG for Blue Button cannot currently support dental and vision claims data. This is the IG we suggest that payers use to make claims data available via the Patient Access API. Generally, if a payer uses the suggested IGs and follows the IGs to spec to build their API, from a technical perspective, the payer will be in compliance with the final rule. As a result, until dental and vision claims are supported by the CARIN IG for Blue Button, we understand that they will not be available via the Patient Access API. 

See also CMS Final Rule Questions and Answers log#3004

09-Nov-2020
  • No labels