As we note below, you will find the contents of the FAQs do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract, as directed by a program. The FAQs are intended only to provide clarity to the public and regulated payers and providers regarding existing requirements under the law, specifically the entities to whom this guidance applies including Medicare Advantage (MA) Organizations, Medicaid Fee-for-Service (FFS) Organizations, Medicaid Managed Care Plans, Children’s Health Insurance Program (CHIP) Managed Care Entities, Issuers of Qualified Health Plans (QHPs) on the Federally Facilitated Exchanges (FFEs) (referred to in these FAQs as “impacted payers") and certain providers.

The information herein addresses certain requirements for impacted payers to build application programming interfaces (APIs) and (for certain impacted payers) to conduct payer to payer data exchanges. CMS 9115-F FAQs also address requirements for certain providers to include digital contact information in the National Provider and Payer Enumeration System (NPPES), and transmit Admission, Discharge, and Transfer Notifications (ADT). These FAQs were printed, published, or produced and disseminated at U.S. taxpayer expense and issued on April 30, 2021. CMS 0057-F FAQs also provide information on updated versions of standards and implementation guides and complying with new prior authorization policies. These FAQs were printed, published, or produced and disseminated at U.S. taxpayer expense and issued on July 1, 2024.

For the regulatory requirements on impacted payers referenced in this guidance, see 42 CFR part 422 for Medicare Advantage plans; 42 CFR part 431 for state Medicaid fee-for-service programs; 42 CFR part 438 for Medicaid managed care plans, 42 CFR part 457 for CHIP programs, and 45 CFR part 156 for QHP issuers on the FFEs.

For the regulatory requirements related to API standards finalized by Office of the National Coordinator for Health Information Technology (ONC) in the 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Final Rule (85 FR 25642) and the Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing (HTI-1) Final Rule (89 FR 1192), see 45 CFR part 170.

Please click below for the published CMS 9115-F and CMS 0057-F FAQs.