What health plans can do today to prepare for the new patient access and interoperability rules

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What health plans can do today to prepare for the new patient access and interoperability rules

September 15, 2020
Business Affairs

Ready, Aim, FHIR
Aside from remaining focused on the above key deadlines, the next most important priority for payers today is to develop plans implementing data-access capabilities via FHIR R4. Though most health plans currently maintain online portals for members, the requirement to provide APIs for members to access data through apps on their phone will likely create challenges for many payers. Importantly, the regulation stipulates that payers will not be able to deliver solutions where only some apps can be used.

Instead, the rule explicitly states that the Patient Access API must include all the required clinical information that payers maintain for each member with a date of service on or after January 1, 2016.


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Adding to the complexity is that some parts of FHIR R4 became normative standards in early 2019, meaning that they are ready for widespread use. Other parts, however, are less mature but will still need to be used by payers.

Five categories of data
Health plans must leverage the FHIR standard to make the following five types of data available: 1) adjudicated claims; 2) encounters with capitated providers; 3) provider remittances; 4) enrollee cost-sharing; and 5) clinical data, including laboratory results.
Most health plans already have systems to provide the first four types of data, which can be mapped to three parts of FHIR, specifically: explanation of benefits; patient; and coverage resources. However, few health plans are well versed with FHIR and many do not yet make data available by API. Many payers have begun investing time and resources into the significant effort required to make this data available. For payers that have yet to begin, there is no time like the present.

Clinical data, the fifth of the above categories, represents the most valuable type of data for patients, but unfortunately also presents the highest hurdle for many plans with less experience managing clinical data. That is because the success of FHIR as an exchange format is dependent on the data being well-structured. However, raw patient data is often incomplete, redundant, or inconsistently coded, and as a result, its value for patient access via FHIR is limited.

For example, information that is poorly formed in the source electronic health record will render incomplete as a FHIR resource. More than just delivering data in the correct FHIR format, payers need a solution that normalizes and enriches raw clinical data so that information presented to the member is complete and useful.

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