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BlockInterop

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CMS Interoperability

We translate CMS interoperability and prior authorization rules into concrete architecture, delivery plans, and operational ownership.

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What we deliver

  • Requirement-to-capability mapping and gap analysis
  • Patient Access, Provider Access, and Payer-to-Payer API design
  • Prior authorization API and workflow implementation planning
  • Attribution, consent, and member matching approaches
  • Compliance evidence and reporting readiness

Outcomes you can expect

A defensible roadmap tied to regulatory milestones
Implementation sequencing that reduces delivery risk
Shared understanding across compliance, IT, and operations

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Answers

Questions We Get About This Work

Direct answers, written to stand on their own.

What do CMS interoperability and prior authorization rules require?

CMS interoperability rules require affected payers to expose health data through standards-based FHIR APIs. That generally includes Patient Access, Provider Access, and Payer-to-Payer APIs, plus prior authorization APIs and reporting that make utilization management decisions and status available programmatically. Meeting the rules is an engineering and operations program, not only a compliance exercise, because it depends on data availability, member matching, attribution, and consent.

  • Map each requirement to a concrete capability, data source, system, and accountable owner.
  • Confirm data availability and quality before committing to API delivery dates.
  • Design member matching, attribution, and consent handling explicitly.
  • Build testing and evidence collection into delivery so compliance reviews are straightforward.
CMS InteroperabilityFHIR and API Implementation

What is healthcare interoperability?

Healthcare interoperability is the ability of different health IT systems to exchange data and use it in a shared, meaningful way. In practice it combines data standards such as HL7 v2 and FHIR, secure APIs and network participation, governance and consent rules, and workflow design so the data arrives where a clinician, member service representative, or research coordinator can act on it.

  • Standards layer: HL7 v2 messaging, FHIR resources and profiles such as US Core, and document exchange.
  • Transport layer: APIs, interface engines, and network participation such as TEFCA and QHIN connectivity.
  • Governance layer: identity, consent, exchange purpose, data stewardship, and audit.
  • Workflow layer: getting the right data into the screen and moment where a decision is made.
FHIR and API ImplementationInteroperability Strategy and Advisory

What is the difference between FHIR and HL7 v2?

HL7 v2 is a message-based standard that pushes events such as admissions, orders, and results between systems over interface engines. FHIR is a resource-based standard that exposes data through RESTful APIs so applications can request exactly what they need. Most organizations run both: HL7 v2 continues to carry high-volume clinical event traffic while FHIR supports apps, partner APIs, and regulatory requirements.

  • HL7 v2 strengths: mature, event-driven, high throughput, deeply embedded in existing clinical operations.
  • FHIR strengths: API access, granular queries, app launch through SMART on FHIR, and regulatory alignment.
  • The decision depends on workflow, latency, partner capability, and who will operate the integration.
  • Migration is usually incremental, with FHIR added alongside existing v2 interfaces rather than replacing them.
HL7 Interface DevelopmentFHIR and API Implementation

Not Sure Where to Start?

Schedule a focused conversation to identify your interoperability priorities, risks, dependencies, and most practical next steps.

Talk With an Interoperability Expert
Book an Interoperability Strategy Call

Ready to Move Interoperability Forward?

Whether you are preparing for new CMS requirements, modernizing healthcare integrations, connecting to a QHIN, or building a FHIR-enabled product, BlockInterop can help you define the right path and execute it.

Book an Interoperability Strategy CallContact BlockInterop

Tell us about your organization, current challenge, timeline, and desired outcome.