Payer-to-Payer and the Provider Directory

When a patient changes plans

People change health plans. When they do, their history should not start from zero. The Payer to Payer A P I moves data from one plan to the next. And the Provider Directory A P I lets anyone find who is in a plan's network.

Three rules for Payer-to-Payer

The Payer to Payer A P I makes a patient's data available to the patient's other payer. The data is claims and encounter data without provider remittances or cost sharing, the data classes and elements of the United States Core Data for Interoperability, and certain prior authorization information, but not for drugs. The patient must opt in first. And payers only have to share data with a date of service within five years of the request.

• Permission · The patient opts in · key
• Content · Claims, USCDI, prior auth · file
• How far back · Within five years · clock

Different defaults, different APIs

Notice the difference in consent. For the Provider Access A P I, the patient may opt out. For the Payer to Payer A P I, the patient must opt in. In both cases the payer must explain the benefits in plain language. So the same data can be shared by default with your own providers, but moves between plans only when you say yes.

The Provider Directory API

The Provider Directory A P I is not new. It was required by the earlier interoperability rule, and the C M S fact sheet refers to the existing Provider Directory A P I. For it the fact sheet recommends a Da Vinci guide called Plan Net.

• Already required · By the earlier rule · check
• Recommended guide · Da Vinci Plan-Net · file

Check yourself

Pause and think. For the Payer to Payer A P I, what must a patient do before data moves? The answer: opt in.

• Opt in
• Opt out
• Pay a fee
• Visit the payer in person

Keep these in mind

Payer to Payer carries data when a patient changes plans. The patient opts in first. Claims, U S C D I data and prior authorizations move. And the Provider Directory A P I already existed.

• Payer-to-Payer carries data when a patient changes plans
• The patient opts in first
• Claims, USCDI data and prior authorizations move
• The Provider Directory API already existed