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Decision Insights™ CMS Payer Interoperability Commentary

Subject Expert
Paul Hess
Research Director
KLAS Research Director - Paul Hess
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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.


Subject Expert
Paul Hess
Research Director
KLAS Research Director - Paul Hess



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