Why the Provider Access API Will Have Value for Payers

About two years ago, we characterized interoperability compliance as a marathon of sprints. For many payers, that’s just what it feels like. If you’ve rounded the corner (or are close to it) on the Patient Access and Provider Directory APIs, your next milestone is likely to be the Provider Access API, proposed for implementation by January 1, 2026. This blog is the first in a series to provide insights for payers as you prepare for Provider Access API requirements.

What is the Provider Access API Rule?

This proposed rule by Centers for Medicare & Medicaid Services (CMS) would require payers to make specific types of health plan member/patient data available to providers via an API that uses the HL7 FHIR standard. Initially, it would only be for providers who have a contract relationship with the payer and a treatment relationship with the patient. There would be future potential to share the same data with out-of-network providers. 

The types of data to be shared include:

• claims (without payment details or patient cost share)
• clinical data as part of USCDI v1
• prior authorizations with a status update in the past year

Providers could initiate a request for access to a patient’s data prior to or during a patient visit. According to the proposed rule, “the proposed Provider Access API has the potential to allow payers to build upon their existing systems and processes to enhance access to patient data, while continuing to protect patient privacy and data security.”

Which payers would need to comply?

In general, payers affected would include Medicare Advantage organizations, state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities (excluding Non-Emergency Medical Transportation (NEMT) PAHPs), and QHP issuers on FFEs. Check here for more detailed information about payers impacted.

Could patients opt out?

Yes, the proposed rule includes provisions for patients to opt out. Payers would need to provide information in plain language to patients about the benefits of opting in, their right to opt out, and how to take the course of action they choose.

Will the Provider Access API have value for payers?

We believe it would. HealthLX was founded on the idea that interoperability is the key to increasing the efficacy of health care through use of data. The Provider Access API has the potential to enable:

• Better utilization management by eliminating manual requests for data and by giving a single provider system access to longitudinal patient records that can better inform care
• Improved patient safety by increasing the ability to predict a patient’s disease path, and assess whether a patient’s safety risk is coming from inside the health system or is part of care that a patient may have received elsewhere
• Greater member engagement by giving members a better understanding of their own health and the ability to communicate more effectively with providers and better coordinate their own care

Watch for future blogs in this series to cover each of these topics in more depth.

What options do payers have for meeting Provider Access API requirements? 

It depends on where you are in the CMS interoperability rules compliance process. If you’re far along with FHIR on the Patient Access API, then you may have the resources to go on to build and maintain a FHIR-based Provider Access API, the good news is, you’ve already gathered most of the data and just need to add prior authorization information. If you’re at this stage or have complied, you’ll want to make sure your foundation is in place for any future changes. Request a free assessment from HealthLX to see how you can leverage your initial compliance investment. 

Payers who haven’t yet complied with the Patient Access API or have fully allocated their resources to meeting Patient Access API requirements may want to consider an interoperability partner like HealthLX. We keep up with the standards and regulations so our Composable Automation™ Platform and Purpose-built Components™ deliver the most flexible interoperability solution in the market. To learn more, request your personal demo today.