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CMS Interoperability and Patient Access Final Rule. 

CMS released the Interoperability and Patient Access Final Rule was on March 9, 2020 and this new rule will reshape how healthcare organizations, payers and providers must run. Enforcement of the new ruling is finally being enacted, but the question organizations should have on their mind is are we ready?   


What is the Interoperability and Patient Access Final Rule?

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The Interoperability and Patient Access final Rule requires healthcare organizations to provide a FHIR®-based Patient Access Application Programming Interface (API) and Provider Directory API, accessible to patients and members by any commercial device. This means patients and members should be able to access all of their health information freely through a third-party app on a smartphone, tablet or desktop. The goal is to empower members and patients in their healthcare journey, encouraging people to be more engaged in their own health. According to CMS, the goal of this ruling is to "establish policies that break down barriers in the nation’s health system to enable better patient access to their health information, improve interoperability and unleash innovation, while reducing burden on payers and providers." Once the ruling is in full effect, providers will have access to an individual’s care history and the full care continuum, allowing for better decision making in care and ideally, better patient outcomes. 

By January 2022, health plans were additionally supposed to have in place an API in place to support seamless payer-to-payer data exchange, allowing for consumers to easily access their health care data and provider information. 

Healthcare organizations that are impacted by the Final Rule are Medicare Advantage (MA) plans, Medicaid state agencies, Medicaid managed care plans, Children’s Health Insurance Program (CHIP) agencies, CHIP Managed Care entities, and issuers of qualified health plans in Federally-Facilitated Exchanges (excluding stand-alone dental plans).

Who does the Final Ruling effect?

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What are organizations responsible for with the new ruling?

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Patient Access Application Programming Interfaces (API): The Patient Access API is a secure interface that makes patient membership, coverages, claims, clinical and RX formulary information available and accessible to the user via any commercial device. Patients should be able to get access to claims, provider encounters with details and their clinical data no more than one business day after a claim is adjudicated or a patient has seen a provider

Provider Directory Application Programming Interfaces (API): Payers have to make provider directory information publicly available via FHIR® standard API. Patients should be able to also access this information via any commercial device. 

Application Programming Interfaces (API) send information back and forth between a user and a website or app.

The Final Ruling was passed in 2020, with enforcement of the ruling scheduled for July 2021. Due to the global pandemic, CMS has refrained from any enforcement. However, CMS is still working towards the goal that in two years from the July 2021 launch, patient access via commercial device will be the standard across the board. Officially, payers were to have implemented these processes for data exchange in place starting January 1, 2022. With another wave of coronavirus, we once again saw a delay. But as we enter a post-pandemic period, delays and pauses have come to an end. Now all organizations who will be affected should be ready as soon as possible for enforcement. 

When does the Interoperability and Patient Access Final Rule go into effect?

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What is the solution to ensure compliancy for the final rule? 


Now for the easy part. We at Vernier are your solution. We are an end to end answer to the Interoperability and Patient Access Final Rule. Within 90 days, you'll be CMS compliant with minimal heavy lifting on your end. Through Vernier, you're members with have access to all of their health information, including all adjudicated claims within 24 hours,  through any commercial platform.

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