CMS Interoperability and Patient Access Rules

1. Rule overview

   Impacted payers (MA, Medicaid, CHIP, QHP on FFEs) and the staged API requirements.

2. Patient Access API

   Claims, encounters, clinical data, formulary and cost data exposed via FHIR R4 with OAuth, within one business day.

3. Provider Directory API

   Public FHIR provider directory using the Plan-Net IG.

4. Payer-to-Payer exchange

   Data exchange when a member changes payers, with member opt-in and PDex.

5. Prior authorization final rule CMS-0057-F

   Prior authorization API, 72-hour and 7-day decision timeframes, denial reasons and public metrics.

6. Reference implementation guides

   CARIN Blue Button, PDex, Plan-Net, Formulary and US Core as the required IG stack.

7. Medicare and Medicaid specifics

   Applicability by program, enforcement dates and exceptions.

Each section links to the official page. Titles and summaries by Extra Credit; the docs belong to their authors.