How New Data Exchange Models Are Transforming Interoperability

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The discussion around interoperability of US healthcare data has been driven by multiple federal regulations. Notably, the 2020 CMS-9115-F rule was a landmark requirement mandating health plans to adopt the FHIR standard and build APIs allowing members access to their own clinical and claims data. However, an even larger transformation is brought by the CMS-0057-F rule released in January 2024. This regulation requires health plans not only to expand patient (Payer-to-Member) data sharing but also to facilitate Payer-to-Payer and Payer-to-Provider data exchange, while automating Prior Authorization processes via the same FHIR API infrastructure. This rule represents more than mere compliance. It is a critical forcing function for the digital transformation of foundational healthcare workflows. Successful health plans must utilize these APIs to understand member behavior and advance risk adjustment programs, or redesign data sharing processes that previously relied on legacy file transfers (like SFTP) into an on-demand access model. The shift demonstrates that FHIR-based RESTful APIs are becoming the standard technical foundation, fundamentally overhauling how data is exchanged in healthcare.