Creating Scalable Payer-to-Payer Data Exchange

Three national health plans partnered with Availity to securely exchange member data via its Payer-to-Payer Connectivity Hub, eliminating the need for time-consuming point-to-point connections and enabling seamless data transfer for informed decision-making.

Challenge

Accessing member data when individuals move to a new health plan has long been a challenging and inefficient process. This fragmentation leads to care gaps, repeated tests, missed early interventions, and increased costs. In response, the Centers for Medicare & Medicaid Services (CMS) is requiring select payers to electronically exchange member claims, clinical data (excluding drug data), and certain prior authorization details via the Payer-to-Payer API by January 2027.

To meet this requirement, some health plans have started building individual point-to-point connections with other payers. However, this approach does not scale. Each new connection requires time-consuming firewall updates, compliance reviews, risk assessments, credential exchanges, and extensive testing. One health plan reported that setting up a single connection could take up to six months. Without a scalable solution, timely compliance—and care continuity—are at risk.

Solution

To solve the scalability challenges of payer-to-payer data exchange, Availity created a centralized hub-and-spoke model that supports efficient, repeatable connections between health plans. In August 2023, three national health plans joined a collaborative cohort to define technical requirements, using the Da Vinci PDex Implementation Guide as a starting point. Together, the cohort and Availity held weekly meetings to align on standards, address limitations in the guide, and establish shared protocols for data documentation, security, and consent.

To prepare for real-world demands, Availity also launched a Mock-Payer Service—allowing cohort members to test interoperability, performance, and security well ahead of the 2027 deadline. The result: a scalable Payer-to-Payer Connectivity Hub that supports the full CMS-mandated process—from requesting and securely retrieving member data from a previous plan to matching, validating, and loading it into the current plan’s system. This standardized approach not only supports compliance but also equips care teams with the insights needed for more informed decision-making and proactive interventions.

Any time you want two payers to integrate, you need to go through the exact same steps every time. There are no economies of scale. It’s the same set of steps every time: firewall rules and changes, compliance review, risk assessments, credential exchanges, testing. It takes us four to six months to set up one payer connection. With Availity’s Payer-to-Payer Connectivity Hub, we do it once.

VP of Interoperability and Clinical Strategy for a National Health Plan

Results

Centralized, Scalable Infrastructure

Successfully implemented a hub-and-spoke architecture that enables secure, standardized data exchange between multiple payer systems via a single connection.