The rule in one view

A rule that put FHIR inside payers

Many health plans in the United States are now required to run FHIR interfaces. The rule behind it is called C M S dash zero zero five seven dash F. In this lesson we see who it covers, what it asks for, and when.

The rule covers impacted payers

The C M S fact sheet calls them impacted payers. They are Medicare Advantage organizations; state Medicaid and C H I P fee for service programs, plus Medicaid and C H I P managed care; and qualified health plan issuers on the federally facilitated exchanges. Exact requirements and dates vary by type of payer.

• Medicare Advantage · Medicare plans · building
• Medicaid and CHIP · Fee for service and managed care · people
• Marketplace plans · Issuers on the federal exchanges · globe

Process rules first, APIs next

The rule has two kinds of requirement, with two sets of dates. The operational provisions, such as decision timeframes, denial reasons and public reporting, generally began on January first, twenty twenty six. The A P I requirements generally begin on January first, twenty twenty seven, and the exact date varies by type of payer. Check the rule itself for your payer.

Four FHIR APIs

The rule asks for four FHIR A P Is. The Patient Access A P I, which already existed from an earlier rule, must now include information about prior authorizations. The Provider Access A P I shares patient data with in network providers who have a treatment relationship. The Payer to Payer A P I moves data when a patient changes plans. And the Prior Authorization A P I lets a provider ask whether a service is covered, send a request, and get a decision.

• API 1 · Patient Access · For patients; now with prior authorizations. · person
• API 2 · Provider Access · For in-network providers. · building
• API 3 · Payer-to-Payer · When a patient changes plans. · share
• API 4 · Prior Authorization · Ask, send, get a decision. · check

Check yourself

Pause and think. Which of these is one of the four A P Is the rule asks impacted payers to run? The answer: the Prior Authorization A P I.

• Prior Authorization API
• Appointment Booking API
• Pharmacy Inventory API
• Staff Rota API

Keep these in mind

The C M S rule requires FHIR A P Is from payers. Medicare Advantage, Medicaid, C H I P and marketplace plans are covered. Process rules came first, and the A P Is generally follow in twenty twenty seven. And there are four A P Is: patient, provider, payer to payer, and prior authorization.

• The CMS rule requires FHIR APIs from payers
• Medicare Advantage, Medicaid, CHIP, marketplace plans
• Process rules first; APIs generally 2027
• Four APIs: patient, provider, payer, prior auth