CMS delays enforcement of data exchange provision for payers

A picture of the CMS's office building

The agency will give health plans more time to implement standards that move clinical and claims information as members change coverage. 

The Centers for Medicare & Medicaid Service will delay enforcement of a provision of the Interoperability and Patient Access final rule that requires payers to exchange member information when they change health plans. 

On September 15, CMS published a series of answers to frequent questions, one of which indicated that it would not begin enforcement of payer-to-payer data exchange requirements on January 1, as required by the Interoperability final rule, which was passed in May 2020. 

CMS said it would be “exercising its discretion in how it enforces” the data exchange provisions “until future rulemaking is finalized.” The rule requires that payers transfer clinical and claims information to a new payer from a member’s old health plan, when a member requests that transfer of information. It’s intended to ensure that a member’s conditions are efficiently communicated and to better support continuity of care and enable the creation of a virtual longitudinal health record. 

The provision is part of an effort to ensure that patients have access to their medical information and that information blocking does not occur. 

While CMS does not specify the technology to be used to facilitate data exchange between payers, it is encouraging payers to use standardized approaches that employ HL7’s Fast Healthcare Interoperability Resource (FHIR) standard. Experts foresee the use of FHIR-enabled application programming interfaces (APIs) to automate the exchange process between payers. 

Many health plans already have implemented some FHIR-enabled technology to comply with some provisions of the final rule that have already gone into effect, such as requirements that patients have access to their medical information, which can be enabled by FHIR so that API-enabled third party apps can access member information from FHIR endpoint servers. 

But even for organizations that have adopted this FHIR infrastructure, it will take time to build on that infrastructure to support payer-to-payer data exchange. While some payers already have capabilities in place, CMS wants to provide time for those health plans that are lagging, according to a series of frequently asked questions. 

“For those impacted payers that are not capable of making the data available in a FHIR-based API format, we believe this enforcement discretion will alleviate industry tension regarding implementation; avoid the risk of discordant, non-standard data flowing between payers; provide time for data standards to mature further through constant development, testing, and reference implementations; and allow payers additional time to implement more sophisticated payer-to-payer data exchange solutions,” said one answer provided by CMS. 

More information on the latest CMS guidance can be found at .