Payer-to-Payer Data Exchange Gap: CMS-0057 Playbook | 1upHealth
The Payer-to-Payer Gap: From CMS-0057 Compliance to Real Data Exchange
The phone is built. Now, who are you calling?
Learn why a CMS-0057-compliant payer-to-payer API and actually exchanging member data are two very different outcomes, and what it takes to close the gap.
THE PROBLEM
A Compliant API Is the Starting Line, Not the Finish Line
CMS-0057 requires health plans to build a Payer-to-Payer Data Exchange API by January 1, 2027. Most plans will hit that deadline. Far fewer will be exchanging meaningful data through it.
Real data exchange takes three layers: live FHIR APIs, a connected payer network, and automated data validation. Most plans have the API. Few have the other layers.
CMS required the phone. It didn't require a phone book, a carrier network, or that anyone on the other end picks up.
THE PLAYBOOK
What's Inside
- What CMS-0057 Requires (and What It Left Out)
- The Hidden Complexity of Implementation
- What Payer-to-Payer Data Is Actually Worth
- Network vs. Compliance Tool: The Questions That Matter
- A Case Study: From Compliant to Connected
"We built the infrastructure. What we didn't have was the network to make it useful. 1upHealth closed that gap without touching what we'd already built."
VP of InteroperabilityLarge National Payer
The Payer-to-Payer Network Strategy
The compliance floor is the same for every plan. What you build above it is not.
Get the full playbook and a clear framework for evaluating whether your organization is building a compliant API or a real payer-to-payer data exchange capability.
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