62.0.1Payer-to-Payer Requests

This section covers the Payer-to-Payer (P2P) requests from the perspective of a Requesting Payer. It explains how the Requesting Payer can identify patients in the source system, request historical patient data, and verify imported records.

62.0.2Member Match

Before requesting any data, the Requesting Payer must identify the correct patient in the source payer’s system.

Request Example:

POST {{PAYER_SOURCE_ENDPOINT}}/Patient/$member-match

{
  "resourceType": "Parameters",
  "parameter": [
    {
      "name": "MemberPatient",
      "resource": {
        "resourceType": "Patient",
        "name": [
          {
            "use": "official",
            "family": "Person",
            "given": [
              "Patricia",
              "Ann"
            ]
          }
        ],
        "gender": "female",
        "birthDate": "1974-12-25"
      }
    },
    {
      "name": "CoverageToMatch",
      "resource": {
        "resourceType": "Coverage",
        "identifier": [
          {
            "system": "http://oldhealthplan.example.com",
            "value": "DH10001235"
          }
        ]
      }
    },
    {
      "name": "CoverageToLink",
      "resource": {
        "resourceType": "Coverage",
        "id": "cov2",
        "contained": [
          {
            "resourceType": "Organization",
            "id": "Organization/org3",
            "name": "New Health Plan",
            "endpoint": [
              {
                "reference": "http://www.newhealthplan.com"
              }
            ]
          }
        ],
        "identifier": [
          {
            "system": "http://newhealthplan.example.com",
            "value": "234567"
          }
        ],
        "status": "active",
        "beneficiary": {
          "reference": "Patient/P123"
        },
        "period": {
          "start": "2020-04-01",
          "end": "2021-03-31"
        },
        "payor": [
          {
            "reference": "Organization/org3"
          }
        ],
        "class": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "group"
                }
              ]
            },
            "value": "A55521",
            "name": "New Health Plan Group"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "subgroup"
                }
              ]
            },
            "value": "456"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "plan"
                }
              ]
            },
            "value": "99012"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "subplan"
                }
              ]
            },
            "value": "A4"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "class"
                }
              ]
            },
            "value": "GOLD"
          }
        ]
      }
    },
    {
      "name": "Consent",
      "resource": {
        "resourceType": "Consent",
        "status": "active",
        "scope": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/consentscope",
              "code": "patient-privacy"
            }
          ]
        },
        "category": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
                "code": "IDSCL"
              }
            ]
          }
        ],
        "patient": {
          "reference": "Patient/P123"
        },
        "performer": [
          {
            "reference": "Patient/P123"
          }
        ],
        "policy": [
          {
            "uri": "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition-hrex-consent.html#regular"
          }
        ],
        "provision": {
          "type": "permit",
          "period": {
            "start": "2024-01-01",
            "end": "2024-12-31"
          },
          "actor": [
            {
              "role": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/provenance-participant-type",
                    "code": "performer"
                  }
                ]
              },
              "reference": {
                "identifier": {
                  "system": "http://hl7.org/fhir/sid/us-npi",
                  "value": "9876543210"
                },
                "display": "Old Health Plan"
              }
            },
            {
              "role": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                    "code": "IRCP"
                  }
                ]
              },
              "reference": {
                "identifier": {
                  "system": "http://hl7.org/fhir/sid/us-npi",
                  "value": "0123456789"
                },
                "display": "New Health Plan"
              }
            }
          ],
          "action": [
            {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/consentaction",
                  "code": "disclose"
                }
              ]
            }
          ]
        }
      }
    }
  ]
}

62.0.3Invoke Export

After a successful member match, the requesting payer can initiate a bulk data export from the source payer’s system using FHIR Bulk Data specifications.

Operation Used:

POST {{PAYER_TARGET_ENDPOINT}}/Patient/$sdh.s2s.invoke-export

Notes:

• Requires prior $member-match to identify patient(s).
• Supports consent-driven data filtering.

62.0.4Target Patient $everything

Once data has been imported into the requesting payer system, the requesting payer can retrieve all FHIR resources for a specific patient to verify completeness.

Operation Used:

GET {{PAYER_TARGET_ENDPOINT}}/Patient/{{Patient ID}}/$everything

For details on Monitoring Requests or Troubleshooting, see Monitoring P2P Exchanges.