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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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Paul Hess
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KLAS Research Director - Paul Hess
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Latest Related Report

CMS Payer Interoperability 2024: How Are Payers Optimizing the Use of Their Solutions beyond Compliance?) Report Cover Image
Performance
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CMS Payer Interoperability 2024: How Are Payers Optimizing the Use of Their Solutions beyond Compliance?
21 May 24
With the initial goal of meeting CMS requirements (e.g., CMS-9115-F), payer organizations have invested heavily in interoperability solutions to transform data into the FHIR format and provide APIs for member portals and other data exchanges. Still, industry-wide usage among patients for these types of offerings is low, with very few enrolled members asking payers for their medical information. As a result, payers need to determine how to utilize the solutions in a way that maximizes their value, especially as some payers report higher price tags from vendors for the technology to support more use cases. To help payer organizations navigate this field, this report examines the performance of CMS interoperability vendors as well as what current and future use cases are a priority for payers.

Report Abstract

Key Findings:

  1. Beyond Compliance, Current Uses of Solutions Most Often Revolve around Data Conversion; Future Use Cases Will Be Focused on EHR Integration & Closing Care Gaps
  2. Smile Digital Health Customers Report Highly Varied Use Cases
  3. InterSystems Builds Strong Customer Relationships but Has Opportunities to Provide More Product Value; 1upHealth Customers Only Report Compliance Work, with Some Considering Leaving
  4. Edifecs & Onyx Technology Customers Highly Satisfied Due to Strong Relationships & Expertise in Compliance
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Performance Data

Overall Score by Product

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Products Appearing in Decisions

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Overall Score by Question Topic

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Provider Facility Size by Product

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Provider Facility Type by Product

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Current Time Inside Cache Tag Helper: 5/17/2025 12:14:52 AM and Model.SegmentId = 445
Related ReportsView All Reports
Point of Light
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Points of Light 2023 Case Study 2
12 April 23    |   Aurene Wilford and Boyd Stewart
Prior authorizations for referrals and clinical procedures are widely acknowledged as a significant pain point for all involved parties—payers, providers, and patients. Using implementation guides from HL7’s Da Vinci Project, the collaborators in this case study created bidirectional data exchange through a FHIR API that enables an automated, in-workflow authorization process. The pilot use cases have been successful, achieving improved efficiency, reduced costs, and—most critically—more timely care and improved patient outcomes.
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.



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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