Availity Payer-to-Payer Data Exchange Cohort Pioneers Payer Connections for CMS Interoperability and Prior Authorization Final Rule

New Report Details Availity’s Partnership with Leading Health Plans in Preparation of CMS Interoperability and Prior Authorization Final Rule Enforcement Deadline

Availity^®, the nation’s largest real-time health information network, announced insights gained and progress achieved through the company’s Payer-to-Payer Data Exchange Cohort Program. Initiated on August 22, 2023, Availity’s dynamic partnership with a select cohort of payers, is pioneering the inaugural set of payer connections within the Availity Connectivity Hub. Serving as a one-to-many connection point, the Availity Connectivity Hub is designed to accelerate interoperability and streamline the Payer-to-Payer Application Programming Interface (API) data exchange process, while minimizing reliance on costly, time-consuming point-to-point connections.

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), which goes into effect on January 1, 2027, will require impacted payers to implement and maintain Payer-to-Payer APIs to exchange clinical, claims, and authorization data when a member moves between health plans. Payers will need a robust infrastructure, including data standardization tools, interoperable electronic health record (EHR) systems, and capabilities for secure health information exchange, to meet the requirements as specified in the U.S. Core Data for Interoperability (USCDI) version 1 content standard.

The Availity Payer-to-Payer Data Exchange Cohort Program aims to address the challenges and hurdles that health plans may encounter when establishing these secure connections with other health plans. By collaborating and testing early, the program aims to identify and address pitfalls and gaps in The Health Level Seven (HL7^®) International Da Vinci Payer Data Exchange (PDex) Implementation Guides in advance of 2027—helping payers sidestep implementation challenges and delays to ensure success.

“While the impending enforcement deadline for the CMS Interoperability and Prior Authorization Final Rule may seem like the distant future, failure to take proactive steps could result in substantial penalties and connectivity delays as much remains unknown in this new landscape,” said Ashley Basile, Chief Product Officer, Clinical Solutions, at Availity. “The network Availity is building with our health plan partners generates multiple economies of scale. By seizing the opportunity to lead, collaborate, and shape the future of healthcare connectivity early, we can collectively drive positive change, ensuring timely, informed decisions that aim to elevate outcomes for health plans, providers, and members alike.”

The white paper details challenges encountered in the program’s first year and spotlights the most efficient and effective methods for establishing a centralized, one-to-many connection point for facilitating member data exchange between health plans. The report also includes:

• Overview of the Payer-to-Payer Data Exchange Final Ruling
• Background on the PDex Implementation Guide
• Cohort Infrastructure Requirements and Standardized Testing Processes/Timelines
• Cohort Findings and Overview of Challenges
• Summary of Best Practices
• Synopsis of Lessons Learned

For additional information, download Availity’s Payer-to-Payer Data Exchange Cohort White Paper.

About Availity

Availity empowers payers and providers to deliver transformative, patient-centered healthcare experiences by enabling the seamless exchange of clinical, administrative, and financial information within established workflows. As the nation's largest real-time health information network, Availity provides mission-critical connectivity and develops intelligent, automated, and interoperable solutions that foster collaboration and deliver shared value across the healthcare ecosystem through omni-channel connectivity. Availity's robust, cloud-first technology platform maximizes efficiency, security, and resiliency through responsible use of AI, data-driven insights, extensive partnerships, and a diversified product portfolio. With connections to over 95% of payers, more than 3 million providers, and over 2,000 trading partners, Availity is setting the standards for the future of disciplined healthcare innovation.

For more information, including an online demonstration, please visit www.availity.com or call 1.800.AVAILITY (282.4548). Follow us on LinkedIn and X.

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