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CMS Payer Interoperability
 

Software designed to meet requirements for CMS-regulated payers and state agencies by providing a patient access API, provider directory API, and payer-to-payer data exchange.

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Joe VanDeGraaff
Research Director
KLAS Research Director - Joe VanDeGraaff
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CMS Payer Interoperability 2022: An Early Look at Purchase Decisions and Vendor Performance in a New Market) Report Cover Image
Performance
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CMS Payer Interoperability 2022: An Early Look at Purchase Decisions and Vendor Performance in a New Market
13 September 22
CMS recently issued a new regulation stipulating that CMS-regulated payers must be able to securely store and share patient data under the HL7 FHIR standard. To achieve this, organizations use CMS payer interoperability products, which usually provide capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. Health plans and state agencies are evaluating how well technology vendors’ existing or newly developed solutions can help them stay compliant with the new CMS requirements. This report is KLAS’ first to validate the purchase decisions and customer experience of some of the vendors in this area.

Recent Insights

Key Findings:

  1. 1upHealth, Edifecs, and Smile CDR See Strong Early Traction
  2. Cognizant and Change Healthcare Already Up for Replacement
  3. Provider-Sponsored Health Plans Often See InterSystems & Epic as Viable Choices
  4. Early Performance Insights: 1upHealth Customers Highlight CMS Expertise & Smile CDR Customers Satisfied with Technology; Respondents across All Vendors Experience Bumpy Implementations


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Performance Data

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Related Articles
Article
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A First Look at CMS Payer Interoperability
01 February 23    |   Ruirui Sun and Joe VanDeGraaff
A new payer interoperability market emerged after CMS announced a mandate on secure patient data exchange, and began enforcing it in July of 2021. Learn more about vendor performance in this follow-up
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Related ReportsView All Reports
White Paper
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CMS Payer Interoperability
04 August 22    |   Joe VanDeGraaff and Ruirui Sun
To enable patients to securely transfer their data from payer to payer as their coverage changes, new mandates dictate that CMS-regulated payers must be able to securely exchange patient data. Several technology vendors are available to help health plans and state agencies comply with these interoperability requirements, providing capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. This vendor guide is intended to help health plans and TPAs understand the vendor technology options; it includes those vendors known to KLAS as of July 2022.
Emerging Technology
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1upHealth FHIR Platform
18 March 22    |   Aurene Wilford and Joe VanDeGraaff
In 2021, new CMS rules came into effect that require CMS-regulated health plans to have a patient access API and a provider directory API. Aimed at increasing the interoperability of personal health data, these rules have prompted payers to look at new ways of sharing external information. This report evaluates 1upHealth‘s FHIR Platform, an interoperability solution designed to help payer customers meet governmental regulations and improve consent and authorization management.
Emerging Technology
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Smile CDR
09 April 21    |   Joe VanDeGraaff and Sam Eaquinto
In 2021, new CMS rules came into effect requiring CMS-regulated health plans to have a patient access API and a provider directory API. These regulations, aimed at increasing the interoperability of personal health data, have prompted payers to look at new ways of facilitating external information sharing. This report offers a first look at Smile CDR, a fast-moving, healthcare-specific solution provider that has recently delivered interoperability solutions to payer customers to help meet the new mandates.
Best in KLAS
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2021 Best in KLAS Awards - Software and Professional Services
02 February 21    |   Mark Allphin and Sam Eaquinto
The Best in KLAS report recognizes software and services companies who excel in helping healthcare professionals improve patient care. All rankings are a direct result of the feedback of thousands of providers over the last year. A Best in KLAS award signifies to the healthcare IT industry the commitment and partnership that the top vendors should provide. Read the report to see the top-rated medical software and services for 2021. Watch sessions from our first-ever virtual Best In KLAS Award Show to hear from the winning vendors in each segment. View Awards Show Recordings



Reducing Filters

Unlike sizing filters, reducing filters DO NOT recalculate scores based on the evaluations that meet these requirements. They narrow the list of solutions to show the vendors and solutions that can meet a specific need.

This data is based on interviews with a sample of the firms' recent clients. As a result, it is not necessarily comprehensive of all work a firm may do in this segment.

We require a minimum of 2 confirmations of a service performed in the last 3 years for a solution to qualify.

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