Payer to Payer API
The Payer-to-Payer API enables secure, standards-based exchange of member data between health plans to support continuity of care during member transitions. It allows receiving payer systems to retrieve claims, encounters, and prior authorization information from previous payer systems through authorized workflows, in compliance with CMS interoperability requirements. The API aligns with CMS-recommended implementation guides, including the CARIN Common Payer Consumer Dataset (CPCDS), HL7® Da Vinci Payer Data Exchange (PDex), and FHIR® Bulk Data. It also leverages data exchange standards such as HL7® FHIR® and SMART Backend Services Authorization).
Capability Statement
Developers can access the Acentra Health FHIR server capabilities for Payer to Payer API using the CapabilityStatement endpoint:
The capability statement describes the set of capabilities (behaviors) implemented by the FHIR Server to enable the Payer to Payer API. For example, it describes the enabled profiles, interactions, search parameters and provides information about the authorization and token endpoints.
API Access Setup
FHIR SMART Configuration
Clients can retrieve SMART configuration details by invoking the SMART configuration endpoint at /.well-known/smart-configuration, appended to the FHIR Base URL.
The FHIR Base URL will be provided upon successful App Registration approval.
Getting Access Token
| Section | Key | Value |
|---|---|---|
| HTTP Method | POST | https://sb.fhir.mhbapp.com/sof/oauth2/token |
| HTTP Headers | content-type | application/json |
| accept | application/json | |
| authorization | Basic base 64({client_id}:{client_secret}) | |
| HTTP Body | code | {oauth code} |
| grant_type | authorization_code | |
| redirect_uri | {your_redirect_uri} |
Operations
Acentra Health Interoperability Solution’s Payer to Payer API supports the following operations
| Operation | Endpoint |
|---|---|
| $member-match | https://sb.fhir.mhbapp.com/p2p/api/v1/Patient/$member-match |
| $bulk-member-match | https://sb.fhir.mhbapp.com/p2p/api/v1/Group/$bulk-member-match |
| $davinci-data-export | https://sb.fhir.mhbapp.com/p2p/api/v1/Group/$davinci-data-export |
Profiles
Acentra HealthInteroperability Solution’s Payer to Payer API supports the following profiles
| Profile |
|---|
| HRex Member Match Request |
| HRex Member Match Response |
| PDex $multi-member-match request |
| PDex $multi-member-match response |
| Prior Authorization |
| Patient |
| Coverage |
| Practitioner |
| Organization |
| Related Person |
| EOB Inpatient Institutional Basis |
| EOB Outpatient Institutional Basis |
| EOB Professional NonClinician Basis |
| EOB Oral Basis |
| EOB Pharmacy Basis |
| Provenance |
Request Headers
All requests for Payer to Payer API profiles require the following headers
| Header | Value |
|---|---|
| content-type | application/json |
| accept | application/json |
| authorization | Bearer |
Sample Queries and Data
Acentra Health Interoperability Solution’s Sandbox environment provides synthetic but reliable dataset to facilitate testing Payer to Payer API. The sandbox dataset is representative of real data and ensures consistency across the dataset.
Important Information for Payer Systems
| Topic | Reference |
|---|---|
| CARIN Alliance Code of Conduct | https://www.carinalliance.com/our-work/trust-frameworkand-code-of-conduct/ |
| Privacy, Security and HIPAA | https://www.healthit.gov/topic/privacy-security-and-hipaa |
| ONC Model Privacy Notice | https://www.healthit.gov/topic/privacy-security-and-hipaa/model-privacy-notice-mpn |