Payer Requirements

Impacted payers must provide educational resources in plain language to their patients about the Provider Access API.

This includes:

  • Member benefits of API data exchange with providers,

  • Patients' opt out rights,

  • Instructions for both opting out of data exchange and for subsequently opting in

Impacted payers must make this information available to patients before the first date on which the payer makes their information available via the Provider Access API, no later than one week after the start of coverage, and at least annually.

These resources must also be available in an easily accessible location on payers' public websites.

Impacted payers must also provide on their website and through other appropriate provider communications information in plain language explaining the process for requesting patient data using the Provider Access API.

  • The resources must include information about how to use the payers' attribution process to associate patients with their providers.

1up will provide draft content to meet these requirements which you will be able to tailor and publish on your website, and use in your member/provider communications.

Member benefits of API data exchange with Providers

  • Facilitates care coordination.

  • More data is available to help providers manage a patient's care and providers could reduce or eliminate duplicate tests.

  • Reduces the burden on patients to recall and relay information during an appointment and/or provide confirmation that the patient's recollection of prior care is accurate.

  • Research shows that patients achieve better outcomes when their record is more complete, and more data are available to the health care provider at the point of care.

  • Supports movement toward value-based payment models.

  • Could lead to fewer duplicate requests for services, fewer appeals and, possibly, lower costs for payers.

Patient opt out rights

  • Payers are required to allow patients to opt out of the Provider Access API.

  • Member must have the option to opt out at any time while the member is enrolled with the payer.

Instructions for both opting out of data exchange and for subsequently opting in

Will be custom to each customer for now - when we build opt out screens we can add more details over the process we control.