Under the CMS Interoperability and Patient Access Final Rule (CMS-9115-F), payers (health insurers) must share specific types of data and make it accessible to designated individuals and organizations:

Data to be Shared

1. Claims Data: Information about healthcare services billed to and paid by the insurer, including details about procedures, dates, and costs.
2. Encounter Data: Records of patient interactions with healthcare providers, including diagnoses and treatment information.
3. Clinical Data: Information related to a patient’s health status, treatment plans, and clinical outcomes.
4. Provider Directory: An up-to-date list of in-network healthcare providers, including their contact information and specialties.
5. Benefit Information: Details about coverage benefits, including cost-sharing requirements and available services.

Organizations and Individuals to Share Data With

1. Patients: Health insurers must provide patients with easy access to their own health information through secure online portals or apps.
2. Healthcare Providers: Insurers need to share relevant health information with patients’ current or prospective healthcare providers to improve care coordination.
3. Third Parties: Patients may authorize third-party applications or services to access their health data. Insurers must comply with these authorizations, provided they meet security and privacy requirements.
4. Health Information Exchanges (HIEs): If applicable, insurers may also share data with HIEs to support broader health information sharing and care coordination.

This sharing is designed to enhance transparency, improve patient care, and facilitate better coordination among different healthcare stakeholders.

Accuracy Requirements

1. Correct Information: Payers must ensure that the data shared with patients, providers, and other entities is accurate and reflects the most current information available. This includes claims data, encounter data, clinical information, and provider directories.
2. Error Handling: Payers must have mechanisms in place to identify and correct inaccuracies in the data. This includes responding to reported errors and making necessary updates to ensure the information is reliable.
3. Consistency: Data shared across different platforms and systems must be consistent, avoiding discrepancies that could lead to confusion or misinformed decisions.

Timeliness Requirements

1. Real-Time or Near-Real-Time Updates: Payers are required to provide real-time or near-real-time access to data. For example, data on claims and encounters should be updated promptly to reflect the most current information.
2. Data Refresh Rates: Specific updates must occur within set timeframes. Claims and encounter data updates are generally expected within one business day, though the exact timing can vary based on the type of data and contractual agreements.
3. Provider Directory: The provider directory must be updated regularly to ensure accuracy regarding in-network providers. Updates should be made promptly to reflect changes in provider availability or network status.
4. Response to Requests: Payers must ensure that systems can process and respond to patient and provider data requests in a timely manner, supporting efficient access and exchange of information.

Under the CMS Interoperability and Patient Access Final Rule (CMS-9115-F), payers (health insurers) must meet specific accuracy and timeliness requirements for data sharing. These requirements are designed to promote transparency, facilitate effective care coordination, and ensure that stakeholders have access to reliable and up-to-date information.