Consumer-Directed Payer Data Exchange
- Release 0.1.0

Consumer-Directed Payer Data Exchange, published by CARIN Alliance. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of and changes regularly. See the Directory of published versions


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The CARIN Alliance

The CARIN Alliance is a bi-partisan, multi-sector alliance to unite industry leaders in advancing the adoption of consumer-directed health care information exchange across the U.S.

We envision a future where any consumer can choose any application to retrieve both their complete health record and their complete coverage information from any provider or health plan in the country. Specifically, we are promoting the ability for consumers and their authorized caregivers to gain digital access to their health information via non-proprietary application programming interfaces or APIs.

Consumer-directed exchange

Consumer-directed exchange occurs when a consumer or an authorized caregiver invokes their HIPAA Individual Right of Access (45 CFR 164.524) and requests their digital health information from a HIPAA covered entity (CE) via an application or other third-party data steward.

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. In early 2018, CMS released Blue Button 2.0 which allows Medicare fee-for-service beneficiaries to access their claims data via an application of their choice. In addition, the CMS Patient Access and Interoperability proposed rule released on March 4, 2019 requires health plans in Medicare advantage, Medicaid fee-for-service, Medicaid CHIP plans, Medicaid managed care plans, and qualified health plans (QHPs) in the federal marketplace to offer consumer access to plan and claims information through standards-based APIs.

The proposed rule includes four types of information for dissemination:

  • Adjudicated claims, appealed payment decisions, provider remittances, enrollee cost sharing within (1) business day after the claim is processed
  • Standardized encounter data within (1) business day
  • Provider directory data, including names, addresses, phone numbers, and specialties no later than 30 days after changes are made
  • Clinical data, including lab results, if available no later than (1) business day after received

The current proposed implementation date is January 1, 2020.

The CARIN Alliance believes the draft CARIN Blue Button implementation guide will help Medicare, Medicaid, and QHP plans to meet the first requirement (adjudicated claims) in the CMS proposed rule.

Building on Blue Button 2.0 and Argonaut

The CARIN Blue Button Framework was designed to answer the challenge for health plans to ‘meet or exceed’ the CMS Blue Button 2.0 capabilities. The CMS Blue Button 2.0 project provides over 53 million Medicare fee-for-service beneficiaries access to their electronic claims information.

The goal of the CARIN Alliance Health Plan workgroup is to develop an agreed upon set of data fields to exchange with consumers and a FHIR-based implementation guide for health plans to use to implement the API.

We used the Argonaut Project as a template for development of the CARIN Blue Button Framework. The Argonaut Project was formed in December 2014 as an implementation community comprising leading technology vendors and provider organizations to accelerate the use of FHIR and OAuth in health care information exchange. The Argonaut project is private-sector initiated and funded and works collaboratively with other FHIR initiatives to create open industry Implementation Guides in high priority use cases of importance to patients, providers and the industry as a whole.

The CARIN health plan workgroup was organized to develop a FHIR-based API that could be sent to a consumer-facing application.

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