Patient Access and Provider Access

Two APIs, two audiences

Two of the four A P Is are about sharing data a payer already holds. One is for the patient. The other is for the patient's own providers. In this lesson we see who sees what, and who is in control.

The patient and the provider

The Patient Access A P I comes from an earlier rule. It gives patients access to their data. The new rule adds information about prior authorizations to it, but not for drugs. The Provider Access A P I is new. It shares patient data with in network providers who have a treatment relationship with the patient, to support care coordination.

Three kinds of payer data

What can a provider see through the Provider Access A P I? Three kinds of data. First, individual claims and encounter data, without provider remittances and without the patient's cost sharing information. Second, the data classes and data elements of the United States Core Data for Interoperability. And third, specified information about prior authorizations, excluding drugs.

• Claims and encounters · No remittances, no cost-sharing · file · navy
• Clinical data · USCDI classes and elements · body · amber
• Prior authorizations · Specified information, not drugs · check · slate

The patient stays in control

The rule builds in patient control for provider access. Payers must keep an attribution process, which links each patient to the in network providers who have a treatment relationship. Patients may opt out of having their data shared with providers this way. And payers must give patients plain language information about the benefits of the exchange, and about their ability to opt out.

• Control 1 · Attribution · Link patients to their providers. · link
• Control 2 · Opt out · A patient may say no. · lock
• Control 3 · Plain language · Explain the benefits and the choice. · text

Check yourself

Pause and think. Which of these can a payer share through the Provider Access A P I? The answer: claims and encounter data, without remittances or cost sharing.

• Claims and encounter data, without remittances or cost-sharing
• A provider's private notes
• A patient's bank details
• Another payer's contract rates

Keep these in mind

Patient Access is for the patient, now with prior authorizations. Provider Access is for in network treating providers. Claims, clinical data and prior authorizations are shared. And attribution, opt out and plain language information protect patients.

• Patient Access is for the patient, now with prior authorizations
• Provider Access is for in-network treating providers
• Claims, clinical data and prior authorizations are shared
• Attribution, opt-out and plain language protect patients