More Data Is Coming to Providers, but Not More Clarity
On January 1, 2027, the payers that run Medicare Advantage, Medicaid, CHIP, and federal exchange plans must switch on a Provider Access API. Under the 2024 CMS interoperability rule, that interface hands an in-network provider the claims, encounter data, clinical data, and prior authorization history for every attributed patient. Payers have one business day to answer a request. Providers have asked for this for years. The data will start arriving in January. Most practices will read very little of it, because they already receive more outside information than they can use.
Half of the rule is already working. Since January, Medicare Advantage, Medicaid, and CHIP plans owe decisions within 72 hours on expedited requests and seven days on standard ones. Every denial needs a specific reason, and each payer had to publish its numbers by March 31. KFF’s first read of those reports found that Medicare Advantage plans denied 12% of standard requests in 2025, Medicaid managed care plans 14%, and Marketplace plans 18%. About two-thirds of appealed Medicare Advantage denials were reversed. The APIs are the second half, and payers are behind. In WEDI’s February survey, 16% of payers expected to be 75% to 100% complete by the deadline, and 10% had not started. The share of providers who called themselves likely to be ready had fallen from 69% to 47%.
Providers already receive outside records at volume, and the problem predates the rule. TEFCA passed 1.5 billion documents exchanged in August, and Carequality reports more than 1.5 billion transactions a month. Use has not kept pace with volume. A 2024 survey asked 8,122 family physicians whether outside information arrived automatically, was easy to find, and was easy to use. The share who said yes to all three ranged from 8% for outside test results to 19% for encounter documents. A Health Affairs study found that every added hour of daily documentation cut the share of patients whose outside record the primary care physician opened by 7.1%. Time, not access, decides whether an outside record gets read.
Payers must share the claims and encounter data they hold, the clinical data elements they maintain, and prior authorization decisions. The claims and clinical data go back to 2016. The payer decides which patients are attributed to which provider, and a patient can opt out of the whole feed but not part of it. Payers maintain claims well and clinical detail thinly, so the feed will be strong on where a patient was seen and what was billed, and weaker on what was found. A claim line for a biopsy at a hospital the oncologist has never logged into tells the practice that a pathology report exists somewhere, and nothing about what it says.
The strongest case for the rule is that payer claims are the one longitudinal record of where a patient has been. No single EHR holds that map, and a practice can use it to find everything else. That is right, and it is the reason the feed matters. But the map is the start of the work. Someone still has to retrieve the pathology report, the infusion record, and the specialist’s note from each institution on the map, read them, and reconcile them with the chart. The rule puts the map in front of the clinician within one business day and leaves the retrieval, the reading, and the reconciliation where they were.
The rule puts the map in front of the clinician within one business day and leaves the retrieval, the reading, and the reconciliation where they were.
Organizations that benefit in 2027 will treat the feed as a trigger. They will use the claims map to decide which records to pull and assemble those records into one history per patient. Every statement in that history links to the source document it came from, and the care team gets the handful of facts a given decision needs. That assembly step sits between the pipe and the decision, and the rule does not build it. Until practices do, the mandate will add documents to the queue and chart review to the day. A clinician who opens the chart in February will have more to read than in December and the same unanswered questions.
A clinician who opens the chart in February will have more to read than in December and the same unanswered questions.
What is the CMS Provider Access API?
It’s an API that payers running Medicare Advantage, Medicaid, CHIP, and federal exchange plans must switch on by January 1, 2027. It gives in-network providers claims, encounter data, clinical data, and prior authorization history for their attributed patients.
How fast do payers have to respond?
Within one business day of a provider’s request.
What data will providers get?
Claims and encounter data, the clinical data the payer maintains, and prior authorization decisions, going back to 2016. Claims data tends to be strong, clinical detail is often thin.
Can patients opt out?
Yes, but only from the whole feed, not part of it.
Will more data reduce chart review?
Not on its own. The feed shows where a patient was seen and what was billed, but someone still has to retrieve, read, and reconcile the actual records.