Are You Ready for CMS-Required Payer-to-Payer Data Exchange? FHIR® API Readiness Survey Finds Significant Shortfalls

By Nancy Beavin | Director, Provider Connectivity at Medica | Co-Chair, The Sequoia Project Payer-to-Payer Workgroup; and Robert Oakley | Strategy & Interoperability at Evernorth Health Services | Co-Chair, The Sequoia Project Payer-to-Payer Workgroup

We are well into 2024, and there are only 21 months left for health plans to comply with the new Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access rules that require regulated payers to send, receive, and incorporate member data. To prepare our own organizations and our health plan industry colleagues, we are gearing up as co-chairs of a newly forming community of practice convened by The Sequoia Project, to help payers implement necessary changes to comply with the new CMS regulations.

With a 5-minute online survey, we are currently gathering insights from payers across the country on their state of readiness to meet future deadlines. There are several new requirements for payers, and, so far, we’ve heard there is still work to be done to be FHIR®-ready across them all.  Although some payers report advanced readiness, having implemented multiple FHIR Implementation Guides (IGs) from organizations such as HL7® and CARIN in accordance with the CMS Rules, other payers report minimal progress toward compliance. No matter where you are in your journey, The Sequoia Project’s FHIR API Readiness survey and new Payer-to-Payer API Workgroup can help.

Preliminary Survey Results:

Payers tell us they are mostly ready for the exchange of USCDI V1 and claims data, with a few saying they still have work to do to meet requirements. However, prior authorization and eligibility determination are the least well-adopted, with work just starting for many survey respondents. Very few of the payers say they believe they are ready for opt-in, data incorporation, and readiness, and FHIR® PARDD API requirements.

Most often, the Data Exchange for Quality Measures (DEQM) FHIR IG has not been implemented and is not likely to be implemented, mostly because it is endorsed but not required by CMS. In general, FHIR IGs not specified in CMS regulation show poor adoption and low likelihood for future adoption, even though embracing these workflows would create a more robust environment of interoperability between payers, with one notable exception.

Overall, the top implementation targets are Da Vinci Payer Data Exchange (PDEX), PDEX Formulary, and PDEX Plan Net. The least prioritized are DEQM and the CARIN IGs, except for the Digital Insurance Card, likely due to their stages of development and lack of regulatory requirements.

What’s Next on the Path to CMS Payer Compliance?

The preliminary survey results highlight many significant challenges for health plans preparing for CMS interoperability compliance by January 2026. While we continue to gather self-reported readiness information from payers, what we’ve heard so far reinforces the value of forming a community of practice to provide a vital, neutral, and trusted space for those responsible for ensuring their organization’s readiness and compliance with federal regulations. We are proud to be the founding co-chairs of such a community convened by The Sequoia Project, and plan to lead the development of guides to assist in development of governance and documentation based on the payer survey results and the experiences and insights of our members.

The payer community needs to embrace interoperability to maximize our collective ability to best serve our members. There’s no need to do it alone when you can learn from industry experts, benefit from shared best practices, and work collectively to inform policy.

Join The Sequoia Project Payer Community of Practice

Test Your Organization’s Readiness To Comply (5-minute survey)