CMS-Regulated Payers: API Testing and Certification for Network Participation
While CMS-regulated payers are not required to set up a sandbox environment, we agree with the CARIN guide’s recommendation for payers to develop and maintain a sandbox environment for every one of their supported APIs and supported third-party developers who are connecting to their app.
Although having a sandbox environment makes it easier for app developers to test connections with individual payers, they are still required to go through this process each time with a new payer and their respective endpoints. This results in additional integration projects that drive tremendous duplicative effort, considering such projects would be multiplied for every app and payer-endpoint connection.
Taking a Network-Based Approach to Conform to FHIR® Standards
The solution for these one-to-one connections is to take a network-based approach where each app and endpoint is a participant. To ensure interoperability, participants not only implement and support certain standards (e.g., FHIR, OpenID Connect) but also test their individual implementations against a common reference implementation to ensure conformance. Successful completion of testing establishes that a solution conforms to the standards it implements and is an essential step to interoperability.
Further Benefits of API Testing and Payer and Patient Access Certification Programs
The Drummond Group, which helps companies navigate complex regulatory compliance and security environments, has a Payer and Patient Access Certification Program designed to precisely serve this purpose. This program provides testing and certification for groupings of FHIR APIs under the CMS Rule, such as Claims and Encounter Data, Clinical, United States Drug Formulary, and Provider Directory.
Authorized testing and certification programs provide external, third-party assessment and confirmation for a particular solution’s ability to conform to FHIR standards and, in turn, enables interoperability in a scalable manner. When trusted third parties perform the testing, validation, and certification of all endpoints on a network, developers that validate their app against that reference will interoperate with all other certified payer endpoints on the network. This shifts testing and validation from a process that each solution must perform with all other network participants, a burden for each participant, to a process that is managed and assured by the certification body on behalf of the network participants. This is a more efficient and reliable approach to testing, certification, and scalable interoperability.
How ZeOmega Can Help
ZeOmega stands ready to support our payer clients in meeting the aggressive timeframes specified by interoperability regulations. HealthUnity is the first interoperability solution to achieve TDRAAP accreditation and Drummond certification. Having both these credentials coupled with HITRUST certification separates HealthUnity from all other platforms on the market—proving it to be a leader for interoperability, security, functionality, and value.
To learn more, contact a ZeOmega expert at firstname.lastname@example.org or 214.618.9880.
Want to learn more? Read about FHIR-based APIs, API Testing & Certification for Network Participation, and Managing the CMS Patient Access Rule with ZeOmega & EHNAC.