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Resources for Payers in the CMS InterOp and Patient Access API Journey

CMS Interoperability compliance is a long-term journey for Payers. IT systems and processes not only have to be realigned to meet the requirements of the new mandate but also must be nimble enough to adapt quickly to changing business models as patient adoption increases. To best meet these demands, payers should focus on putting together an FHIR infrastructure that complies with the mandate and provision it to extend and scale as the mandate as patient adoption evolves.

The following are the key focus areas and corresponding enabling resources that payers should be looking for in a vendor solution. Utilizing these resources can help your organization prioritize and efficiently comply with the new mandate.

Data Mapping

The mapping of data elements from your source systems to the FHIR profiles is an activity that can get complicated if the payer has multiple source systems or different implementations of the same vendor product. Payers should look for a solution that comes with a reference mapping, like X12 to FHIR, and source system specific mapping such as Facets to FHIR. In addition, the vendors are expected to provide services to enable the payer’s IT team to perform source system mappings, data migration, and conformance validation.

Data Conversion

Initial and ongoing data loading process comprises of data extraction from source systems, validation, conversion to FHIR, and loading them into FHIR repository. Payers should look for tools to help automate the initial and ongoing data processing. Some of the capabilities needed for this processing include:

  • Connectors – for extracting data from source systems or flat files.
  • Mappers – helpful for transforming the data from the source format into FHIR resources by applying appropriate mapping templates.
  • Bulk ingestion – Capability needed for initial data provisioning to load huge volumes of historical claims. Real-time data loading and update are also needed to accommodate for new claims and adjustments to existing claims.

Compliance Testing

Conformity with the mandate is critical. Payers should look for an integrated conformance testing capability from vendors that verifies the FHIR resources are conformant to FHIR R4 specification and adheres to DaVinci & Carin BB implementation guides. The solution should also provide periodic reports of conformance for third party access and FHIR resource payloads.

Periodic Updates

All vendors should provide an ability to support multiple FHIR specifications and CMS mandate updates. Payers should expect the solution to outline the data migration process to move to newer FHIR specifications as the standards evolve. The solution roadmap should also offer periodic updates to accommodate regulatory and specification changes.


A critical feature is the ability to accommodate data and transaction growth. Payers should look to scale the solution to accommodate data growth and increases in patient adoption of third-party apps. Payers should evaluate the solution to have capabilities that dynamically scales the infrastructure progressively for optimal utilization.

Security Controls

Ongoing monitoring for security and usage of the FHIR infrastructure by stakeholders is a must. Payers should look for solutions that are hosted in a HITRUST compliant infrastructure. The solution should inherit and implement controls around identity management, access control, third party access, incident management, and risk assessment.

Reporting Insights

Look for options to gather operational reporting to manage and maintain the FHIR infrastructure. Payers should look for default operational reports and ad-hoc reporting capabilities to support operational activities. Some of these activities include managing errors in data feeds from source systems, reconciliation of members, claims with source systems, and usage from third-party apps.

Data Analytics

Be able to filter and extract data from the FHIR repository. Payers should be looking for ways to extract data from the FHIR repository and make it available to an analytics platform for performing various workloads related to population health analytics.

For more information on how we can help your organization comply with the new mandate, learn more about Sagitec’s HealFHIR.

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Topics: HealConnect Medicaid