Developers | Interoperability

Interoperability

In May 2020, the Centers for Medicare & Medicaid Services (CMS) put forth new rules that create a more consistent framework for interoperability and increase access to electronic health data. This ruling helps improve the quality and accessibility of information that consumers need to make informed health care decisions.

This ruling shifted responsibility of your health care data to you as the member and owner of that data. This change in responsibility for protecting your data means that you as the member have more control over who can access your health care data and you have more responsibility to protect your health care data.

The available information includes claims and encounter information for as long as Priority Health maintains it in its records. This access is for any member who has a Medicaid plan, including MIChild, Healthy Michigan Plan and Children's Special Health Care Services (CSHCS) plan, Medicare Advantage plan, or purchased a Qualified Health Plan (QHP) on the Federally-Facilitated exchanges through Priority Health.

CMS rules on interoperability limit what health insurance companies can do to stop apps from asking you to access your health data. Priority Health believes it is important to provide you with educational resources concerning the privacy and security of your protected health information (PHI) in the context of disclosures of your information to third-party apps.

Priority Health has partnered with 1UpHealth to enable this capability. Members can request this information using one of the approved third-party applications (app).

What does this mean for Priority Health members?

You can now direct the sharing of your medical history and health plan records with other services and applications outside of Priority Health. Active Priority Health members with a member portal login can permit third-party applications to receive the following data:

All claims and medical history information that is stored and controlled by Priority Health;
Encounters with capitated providers; and
Clinical data, including laboratory results (when maintained by the payer)

Steps you may take to protect your privacy and security

Review the app’s Privacy Policy and/or Terms of Service:

What should a member consider if they are part of an enrollment group?
What are a member’s rights under the Health Insurance Portability and Accountability Act (HIPAA) and who must follow HIPAA?
Are third-party apps covered by HIPAA?
What should a member do if they think their data has been breached or an app has used their data inappropriately?

Transparency in health care

In October 2020, the Federal government issued new requirements for health plans and health insurers designed to increase the availability of health care cost information related to Individual and most group plans. The Transparency in Coverage rule includes a phased approach to developing cost transparency services.

Phase 1: Machine-readable pricing files

The first item in the rule requires that machine-readable pricing files be made publicly available. These files provide negotiated rates for items and services between Priority Health and in-network providers; and certain historical payments to out-of-network providers.

We have provided links to machine-readable files in .json format, as required by CMS. They are extremely large (over 100GB) so plan accordingly.

Click on the plan type to access the associated in-network rate files. If unsure, the Table of Contents indicates alignment of groups with plan types. For the out-of-network historical detail, select the Out-of-Network file.

Phases 2 & 3: Future transparency requirements

As we move forward, we will be working to enhance our self-service estimation services and ensure alignment with the next series of transparency rule timelines and requirements.

Protecting your information

We take your privacy and the security of your health information seriously, as reflected in our privacy policy. However, it is important to understand that once your data is shared with a third-party application, Priority Health is no longer responsible for the security of that data.

It is important to read the privacy and security policies for any application you choose to share your data with to understand how your data is protected and used by the application. It's up to you to choose the apps or other services you want to use.

Meeting requirements

To fulfill interoperability and transparency requirements, Priority Health has partnered with 1upHealth to provide secure patient, provider and third-party access to electronic health data for Patient Access API and Provider Directory API. This is in accordance with the Interoperability and Patient Access final rule (CMS-9115-F), which regulates Medicare Advantage (MA), Medicaid, CHIP and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).