Data Strategy Briefing — CMS finalizes Interoperability and Patient Access rule

Executive briefing: CMS finalized the Interoperability and Patient Access rule (CMS-9115-F) on 9 March 2020. The regulation requires Medicare Advantage, Medicaid, CHIP, and federally facilitated Exchange plans to provide standards-based FHIR APIs for patient data access, payer-to-payer exchange at enrollment, and improved provider directory accuracy.

What changed

• Participating payers must implement Patient Access APIs delivering claims, encounter, and clinical data within tight timelines.
• Payer-to-payer data exchange is required when a member changes plans to ensure continuity of care information.
• Public provider directory APIs and Admission, Discharge, and Transfer (ADT) event notifications are mandated for specified hospitals.

Why it matters

• Enforces standardized, patient-directed data portability across payers, aligning with ONC Cures Act requirements.
• Requires engineering teams to build secure, standards-based APIs with consent and identity controls that meet CMS deadlines.
• Non-compliance risks enforcement and impacts plan participation in federal health programs.

Action items for operators

• Validate FHIR API designs, authentication, and consent flows against CMS implementation guides and testing tools.
• Plan payer-to-payer data exchange pipelines and retention policies to support member transitions.
• Update provider directories and ADT notification capabilities to meet publication accuracy and timeliness requirements.