Fostering Payer Data Exchange Through Collaboration and Testing

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F) has spurred health plans to jump-start their payer-to-payer data exchange strategies. As the mandatory enforcement date of January 1, 2027, draws near, neglecting proactive measures could lead to significant penalties and connectivity disruptions. It is critical for health plans to act promptly and decisively in tackling the obstacles and complexities associated with establishing secure connections with other health plans to exchange member data.

Considering the final rule’s requirements, undertaking this endeavor without the guidance of an experienced partner could prove to be quite demanding. This is due to the infrastructure needed to make point-to-point connections with health plans, technical aspects of sending and receiving data, and the imperative for health plans’ internal teams to stay updated on evolving standards.

That’s why we’ve established a cohort program with three leading health plans to pioneer the establishment of the inaugural set of payer connections within our cutting-edge Connectivity Hub.

Payer-to-Payer Data Exchange Testing Plan

Using the Da Vinci PDex Implementation Guides as a roadmap, the cohort aimed to achieve two primary goals. The first was to uncover any hidden challenges or pitfalls associated with payer-to-payer connections. The second was to determine the most effective and repeatable process for establishing a one-to-many connection point through our Connectivity Hub.

Over the course of several months, Availity orchestrated recurring workshops uniting technical teams from each health plan. These gatherings were dedicated to exploring strategies and considerations for executing payer-to-payer data exchange. Participants engaged in discussions about their organization’s overarching interoperability strategy and the resources involved for implementation. They also actively participated in real-world data exchange testing.

The features we tested to validate the effectiveness and robustness of our system are outlined below:   

• Initial Authentication: The validation process ensures only authorized Health Plans can establish connections and exchange data within the network. 
• Member Match: A transaction to determine a definitive, unique match for a member and return a unique member ID.
• Token Request: Ensures authorized access is granted to the new Health Plan so they can proceed to query the member’s data from the PDex Clinical FHIR^® APIs.
• GET $Everything Operation: A mechanism used to return all the information related to one or more members.

For an individual member request, Availity mapped requests, request parameters, responses, tokens, and URLs so that the end customer could react as normal while Availity, an intermediary, brokered transactions. Availity further worked with its network to manage data governance issues regarding these transactions. 

From functionality testing to performance evaluation, each aspect of our solution underwent meticulous scrutiny. When executed, this test plan aimed to accomplish:  

1. Testing Availity’s Payer-to-Payer solution brokering transactions.  
2. Testing each payer acting as a member’s new Health Plan in an isolated scenario.  
3. Testing each payer acting as a member’s new Health Plan with a real trading partner. 
4. Testing each payer acting as a member’s old Health Plan with a real trading partner.  

The Importance of Testing & Collaboration

With the mandatory enforcement date of January 1, 2027, quickly approaching, it is crucial for health plans to establish comprehensive testing environments. They must also actively engage with other health plans to develop effective strategies and share lessons learned. This collaborative approach will pave the way for improved teamwork and innovation in this critical area. By sharing insights and best practices for facilitating member data exchange, we aim to help health plans proactively address connectivity issues. This approach will help them avoid significant penalties and disruptions.

Stay tuned for future blog posts on this topic and more insights!

About the Author

Justin Howe brings 20 years of experience in Healthcare IT to his role at Availity. He leads Product teams focused on interoperability use cases, clinical data acquisition, and advancing FHIR adoption. Justin has worked in implementation, support, and technical services roles in both an EDI clearinghouse and clinical data warehouse environments. He is a passionate advocate for reducing the overall burden on both providers and payers. Justin believes in the importance of thoughtful approaches to solving difficult challenges.