On this page:
  • Explanation
  • 59.0 Overview
  • 59.1 Actors, Roles & Data Scope
  • 59.2 Solution Modules & Standards
  • 59.3 Matching Logic
  • 59.4 Data Exchange Patterns
  • 59.5 Security & Privacy Framework
  • 59.6 Glossary of Terms
    • 59.1    Actors, Roles & Data Scope   
    Table of Contents

    Overview

    59.0.1Payer to Payer Solution Overview

     

    The Payer-to-Payer (P2P) exchange solution helps U.S. health plans meet federal and state regulations that require the exchange of clinical records at a member's request. This benefits patients by ensuring the portability of their health records while enabling payers to utilize health histories to enhance care management.

    59.0.1.1Purpose of This Documentation

    This documentation is designed for technical implementers and business stakeholders to:

    • Understand the capability of the Smile CDR P2P solution
    • Plan for implementation
    • Learn how the solution supports CMS mandates for data exchange
    • Understand how the exchange works
    • Identify key components in the Smile CDR platform that support the exchange

    59.0.1.1.1Supported Use Cases

    These are the high-level use cases that the solution supports:

    Use CaseDescription
    Retrieve and StoreSupport payers to retrieve and store FHIR records from other payers at member request
    Share RecordsSupport payers to share FHIR records to other payer applications, including records from other payers if received in FHIR format

    59.0.2Regulatory Context

     

    59.0.2.1CMS 0057-F Mandates

    The CMS Interoperability and Prior Authorization Final Rule (CMS-0057) requires Medicare Advantage (MA) organizations, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the Federally-facilitated Exchanges to implement and maintain a secure, encrypted, HIPAA-compliant API that exchanges member data with other payers at the member's request.

    The regulation mandates a mix of clinical and financial records be shared with other payers at a member's request.

    59.0.2.2State Regulations

    Various state regulations also mandate data portability requirements for health plans operating within their jurisdictions, often with specific timelines and technical requirements.

    59.0.3Supported Implementation Guides

     

    Smile CDR Payer-to-Payer exchange solution follows these Implementation Guides (IGs):

    Implementation GuideVersionPurpose
    Da Vinci Payer Data Exchange (PDex)2.1.0Single-member and multi-member data exchange
    Da Vinci Health Record Exchange (HRex)1.1.0$member-match operation
    Bulk Data Access IG2.0.0System-to-System exchange using $export
    SMART App Launch2.2.0Authorization between backend services
    US Core3.1.1 and 6.1.0Core FHIR profiles
    CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button)2.1.0Describes the data set payers must make available
  • Explanation
  • 59.0 Overview
  • 59.1 Actors, Roles & Data Scope
  • 59.2 Solution Modules & Standards
  • 59.3 Matching Logic
  • 59.4 Data Exchange Patterns
  • 59.5 Security & Privacy Framework
  • 59.6 Glossary of Terms
    • 59.1    Actors, Roles & Data Scope