Payer-to-Payer Data Exchange API
The Payer-to-Payer API enables health insurance payers to exchange member health data when a member transfers from one health plan to another. This ensures continuity of care and comprehensive data availability at the new plan.
Regulatory Mandate
- Required by CMS-0057-F
- Compliance deadline: January 1, 2027
- Applies to MA, Medicaid/CHIP managed care, and QHP issuers
How It Works
Step 1: Member Enrollment
When a member enrolls in a new health plan, the new payer identifies that the member had prior coverage with another impacted payer.
Step 2: Member Consent
The new payer asks the member if they want their data transferred from the previous payer. This is an opt-in process — the member must explicitly consent. The member can choose not to participate.
Step 3: Member Matching
The new payer sends a $member-match request to the previous payer using the Da Vinci PDex IG:
- Submits member demographics (name, DOB, gender) and old coverage information
- Previous payer matches the member in their system and returns a unique identifier
Step 4: Data Retrieval
Using the member identifier, the new payer requests data from the previous payer:
- FHIR Bulk Data ($export) for large-scale data retrieval
- Up to 5 years of historical data
- Data includes claims, clinical information, encounters, and coverage
Step 5: Data Integration
The new payer incorporates the received data into their systems, making it available through:
- Provider Access API (for treating providers)
- Patient Access API (for the member)
- Internal care management and utilization review processes
Data Exchanged
| Category | Details |
|---|---|
| Claims data | Up to 5 years of adjudicated claims (professional, institutional, pharmacy, dental) |
| Clinical data | Conditions, medications, allergies, procedures, lab results, immunizations |
| Encounter data | Visit history across all care settings |
| Coverage information | Previous plan details, benefit periods |
| Prior auth decisions | Historical prior authorization requests and outcomes |
Technical Standards
- Da Vinci PDex IG — Payer data exchange workflows
- Da Vinci HRex IG — Trust framework and common resources for health record exchange
- $member-match operation — Patient identity matching between payers
- FHIR Bulk Data Access — Large-scale data export
- SMART Backend Services — System-to-system OAuth 2.0 authorization
Implementation Considerations
- Trust framework — Payers must establish a trusted network for data exchange (mutual TLS, OAuth client credentials)
- Data provenance — Received data should be tagged with its source for downstream consumers
- Data freshness — Payers must provide data within a reasonable timeframe after member consent (CMS expects within 1 business day for the $member-match response)
- Error handling — Robust handling for unmatched members, consent revocations, and partial data availability
