Beyond Compliance: 7 Benefits of Payer-to-Payer Data Exchange

The Payer-to-Payer Application Programming Interface (API), part of the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), presents a significant opportunity for health plans. By enabling the secure exchange of historical health data between payers, this API allows plans to access a more comprehensive view of their new members’ clinical, claims, and authorization information. With this complete data, health plans can more effectively coordinate care and improve health outcomes right from the start.

In this blog, we’ll outline the top seven ways health plans can benefit from payer-to-payer data exchange.

1. Seamless Continuity of Care

Through payer-to-payer data exchange, health plans can access a member’s full medical history, including past diagnoses, medications, chronic conditions, and care plans. This minimizes the chances of missed treatments, duplicate testing, and medical errors caused by incomplete information. It also allows health plans to quickly identify members who need specialized or ongoing care, ensuring they receive timely and appropriate treatment from the start of coverage.

• Uncover early identification of care needs: Health plans can quickly pinpoint members who require specialized or ongoing care and enroll them in care management programs without delay.

• Reduce the risk of treatment gaps: Immediate access to medical history lowers the chances of missed treatments or delays in care, ensuring continuity for members.

• Prevent duplicate tests: With full medical records on hand, health plans can avoid ordering redundant tests, saving time and resources.

• Minimize medical errors: Having complete and accurate information reduces the risk of medical errors caused by incomplete or missing data.

2. Faster Enrollment into Care Management Programs

When health plans onboard new members, they often allocate substantial time and resources to chart chasing—a process used by many commercial, Medicaid, and Medicare Advantage plans to collect medical records for specific members. This effort not only strains the resources of health plans but also places a burden on providers, who frequently receive requests from multiple payers for the same medical information.

In some instances, it may take months or even up to a year for a health plan to obtain complete historical information about their new member. Such delays hinder the clinical benefits that could be gained from having this information in real-time. Having access to member data within a week of enrollment allows health plans to quickly identify high-risk or chronic care members, ensuring they can be promptly enrolled into the appropriate care management programs.

3. Enhanced Risk Adjustment Accuracy

Payer-to-payer data exchange enables health plans to more accurately assess the risk levels of new members by providing a complete picture of their health history. Instead of relying solely on self-reported data or waiting for claims information to trickle in, health plans can immediately access comprehensive records, including past diagnoses, treatments, and hospitalizations. This richer dataset allows for more precise risk stratification, helping health plans quickly identify high-risk members, particularly those with chronic conditions or multiple comorbidities who may require more intensive care management.

By understanding a member’s health risks upfront, health plans can effectively allocate resources to high-risk populations, ensuring that those who need the most care receive timely attention. Additionally, having complete health information empowers health plans to implement proactive measures and interventions, reducing costly emergency visits and hospitalizations in the future. Overall, improved risk stratification through payer-to-payer data exchange helps health plans focus on members with urgent needs, leading to better outcomes and cost savings.

4. More Accurate Quality Measurement

Clinical information is frequently left behind when a member changes health plans, particularly when it relates to preventive care and chronic condition management. With Payer-to-Payer data exchange, your plan can access that history from the member’s former insurer and see a more complete and accurate picture.

This will allow your health plan to:

• Count closed care gaps from the previous plan year: If a member already completed a screening or received a recommended service while on their old plan, you’ll have access to that information. This will allow you to count that service as you work toward your current year quality scores, where it would otherwise be overlooked.

• Avoid misclassification of members as non-compliant: If member history is unavailable, the Payer may be left with the impression that a member has open care gaps. This not only skews the quality metric, it can lead to unnecessary outreach to members who have actually met their preventive service needs.

• Improve Star Ratings with less supplemental burden: By avoiding manual chart review and chasing down medical records, your team will have the time to make quality improvement efforts count and improve overall performance.

With a more complete view into a member’s care history, health plans can report more accurately, intervene more effectively, and make measurable progress on quality goals.e members receive timely care, leading to fewer delays and improved satisfaction.

5. Enhance Member Experience

Following the open enrollment period, members often find themselves burdened with having to recount their medical history to their new health plan and in-network primary care provider (PCC), which includes detailing medications, allergies, and medical conditions. Without access to mapped and standardized clinical and claims data, this verbal account becomes crucial for the new health plan and PCC as they work to understand the member’s healthcare needs and develop appropriate care strategies. However, relying on the member’s verbal account can lead to potential complications, such as the repetition of tests or the need to change doctors, both of which can disrupt continuity of care and create frustration for everyone involved in the member’s healthcare journey.

In contrast, payer-to-payer data exchange facilitates a smoother transition by providing health plans with immediate access to comprehensive health records. This reduces the burden on members to repeat their medical histories and helps prevent unnecessary delays or errors in their care. By streamlining this process, health plans can enhance the member experience, foster trust, and ensure that individuals receive timely and effective care right from the start.

6. Streamline Prior Authorization

The payer-to-payer data exchange also simplifies the prior authorization process, which can often be time-consuming and frustrating for both providers and members. By having real-time access to a member’s past authorization approvals, claims data, and clinical history, health plans can streamline prior authorization requests in several ways:

• Faster decision-making: With access to previous authorizations and relevant medical records, health plans can make quicker and more informed decisions about current requests, reducing approval delays.

• Reduction in administrative burden: By eliminating the need to manually gather information from providers or other sources, health plans can reduce the administrative workload associated with prior authorizations, benefiting both their internal teams and healthcare providers.

• Improved provider relationships: Streamlined prior authorizations lead to faster approvals and less frustration for providers, strengthening relationships and encouraging better care coordination.

By reducing the time and complexity of the prior authorization process, payer-to-payer data exchange helps ensure members receive timely care, leading to fewer delays and improved satisfaction.

7. Better Member Matching and Data Integration

Creating a comprehensive view of a member’s care journey requires more than raw data access. It relies on the ability to match, connect, and activate that data across systems and over time. When identity resolution and data activation tools are put to work, Payer-to-Payer APIs can be transformed into powerful, longitudinal member records that drive more impactful analytics and outreach. This means:

• Support for personalized outreach and targeted care interventions

• Faster and more accurate member identity resolution across systems

• Creation of unified, longitudinal member records for a full care view

• Support for personalized outreach and targeted care interventions

A Smarter Path to Compliance

Availity and Onyx deliver a fully managed, future-ready interoperability platform that accelerates CMS compliance while minimizing operational complexity. By combining Availity’s extensive national network with Onyx’s FHIR-native OnyxOS platform, health plans gain a single, secure, and scalable entry point to meet all CMS interoperability mandates:

• Payer-to-Payer API
• Prior Authorization API
• Provider Directory API
• Patient Access API
• Provider Access API

Whether you’re preparing for upcoming deadlines or expanding your digital infrastructure, the Availity network and OnyxOS platform simplify the path forward. Our solution is built for scale, validated in production, and backed by experts who stay ahead of CMS rule changes, so you don’t have to.

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