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For Payers
Complying with CMS requirements for Provider Directory APIs
The CMS Final Rule on Interoperability and Patient Access requires that health insurers publish a Provider Directory API with information about in-network providers. This information is used by patients to search for in-network providers and evaluate health plan networks. Providers also use this information to assist with referring patients to other in-network providers. Defacto Health has observed that over 73% of payers have published a Provider Directory API since the July 2021 rule enforcement date.
Four steps to integrate with your Provider Directory API
Discover
Test
Integrate
Query
Discover
We look on your website or payer API endpoint directories for information about your API. To comply with CMS documentation requirements for Provider Directory APIs, make sure you have clearly published information about your API, its URL, and any connection or approval steps on your web site. Contact information for your tech team or vendor support staff is also important to avoid blocking access.
Test
We test your Provider Directory API to confirm that all important data is present and queryable.
- We confirm that key data elements are available: Provider Names, NPIs, Addresses, Specialties, Organization Affiliations, and Insurances Accepted.
- We confirm that we can query Practitioners, Organizations, Insurance Plans and related data attributes.
- Most importantly, we confirm that a patient can determine whether a Provider accepts one or more of your Plans, and that a patient can see the composition of a Plan’s network.
Integrate
Once successfully tested, we build the integration with your API. We have successfully integrated with over 100 payers’ APIs to date. If we encounter any issues in the course of building the integration, we will be in touch with your team to report these and collaborate on resolution.
Query
Finally, we initiate querying to collect regular updates from your API. Data from your API helps power in-network provider search, health plan comparison, and a range of analytics use cases through Defacto’s partners. Our successful integration with your API helps confirm your compliance with the Rule.
How We Can Help You
We want to help payers, at no cost, ensure their Provider Directory APIs present data that patients need to search for in-network providers and make the best decisions about health plan enrollment.
We can test your Provider Directory API
We can test your Provider Directory API and provide test results (and issue reproduction steps) to your technical team. We can test and confirm issue resolutions as well. We usually turn these tests around to your team within 1 or 2 business days.
We can issue a letter stating that your API supports CMS Rule requirements
Once successfully integrated, upon request, we can provide a signed letter stating that your Provider Directory API is functional and provides sufficient data to support patient use cases. Your organization will appear on a list of integrated payers that is viewable by regulatory bodies.
Your API will help improve your members’ experience
Through our partners, your data will have a positive impact on millions of patients across the country, as they search for in-network providers, evaluate and select health plans, and as providers refer them to other in-network providers. Your API will help make the healthcare experience more seamless for your members as they leverage your plan information in a variety of digital and in-person contexts.