ExplanationOfBenefit System API - Implementation Template (CARIN Blue Button 2.0)
Use case
Data from health plans is not currently available to a consumer through an open API framework and therefore is not accessible by third-party applications authorized by the consumer. The Centers for Medicare & Medicaid Services (CMS) finalized on May 1st, 2020, its Interoperability and Patient Access Final Rule on patient access to health data. Under the final rule, Medicare Advantage (MA) plans, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid and CHIP managed care plans, and qualified health plan (QHP) issuers in the federally-facilitated exchanges (FFEs) must meet certain requirements regarding patient access to their health care information, including requirements related to application programming interfaces (APIs). CMS provides Implementation Guidance for the following data types that make-up the Patient Access API:
- Claims & Encounter Data
- Clinical Data
- Plan Coverage and Formularies
The Consumer Directed Payer Data Exchange Implementation Guide was defined by the CARIN Alliance to meet CMS requirements to provide Claims and Encounter data.
- Provisioning Clinical Data is defined by the DaVinci Payer Data Exchange (PDex) and US Core Implementation Guides.
- Provisioning Plan Coverage and Formularies is defined by the DaVinci Payer Data Exchange US Drug Formulary Implementation Guide.
The effective date of the CMS Interoperability and Patient Access rule is January 1, 2021.
API-led architecture
Implementation templates included
See the RAML asset for the API specification.
| Resource | Definition |
|---|---|
| ExplanationOfBenefit | The ExplanationOfBenefit (EOB) resource combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim. |
| Coverage | The Coverage resource is intended to provide the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services. |
| Organization | This resource may be used in a shared registry of contact and other information for various organizations or it can be used merely as a support for other resources that need to reference organizations, perhaps as a document, message or as a contained resource. |
| Patient | This Resource covers data about patients and animals involved in a wide range of health-related activities |
| Practitioner | Practitioner covers all individuals who are engaged in the healthcare process and healthcare-related services as part of their formal responsibilities and this Resource is used for attribution of activities and responsibilities to these individuals. |