All impacted payers must implement and maintain these HL7® FHIR® APIs to improve electronic health information exchange and streamline prior authorization processes.
Extend existing Patient Access APIs to include prior authorization decisions, giving patients complete visibility into authorization status, claims data, and how prior authorization impacts their care.
Enable in-network providers to access patient data for care coordination and support value-based payment models. Providers with a treatment relationship can retrieve comprehensive patient information.
Support care continuity when patients change health plans by enabling seamless data exchange between payers. Includes up to 5 years of historical claims, encounter data, and clinical information.
Streamline prior authorization processes with electronic submission, real-time decision support, and automated status updates. Must support both HIPAA X12 278 and FHIR-based requests.
Maintain a public, no-authentication provider directory API with current information about all contracted providers, facilities, and services. Must reflect changes within 30 days.