Is your plan ready for TEFCA?
The Cures Act tasked the Office of the National Coordinator for Health Information Technology (ONC) with establishing a national framework for interoperability known as the Trusted Exchange Framework and Common Agreement (TEFCA). TEFCA provides a single on-ramp for healthcare stakeholders to exchange data, including payers. The Sequoia Project, which serves as the Recognized Coordinating Entity for TEFCA, released the second draft version of the Common Agreement in 2024, paving the way for broader data exchange.

Unlike the first version of the Common Agreement, which focused primarily on health information exchange for treatment and individual access, the latest iteration covers operational use cases relevant to payers, including uses related to quality improvement, risk adjustment and payment integrity. One of the most significant decisions for health plan leaders will be whether to join a qualified health information network (QHIN) and participate in TEFCA data exchange. A QHIN is a network of organizations (participants and sub-participants) that connect directly to each other to promote interoperability. To date, seven QHINs have completed the onboarding process to facilitate nationwide data exchange as outlined by TEFCA. These include KONZA National Network, eHealth Exchange, CommonWell Health Alliance, Health Gorilla, MedAllies, Epic Nexus and Kno2.

Health plans that opt to not join a QHIN may take advantage of TEFCA through a delegate partner. A delegate can handle the technical work to acquire data on behalf of any health plan listed in the Recognized Coordinating Entity (RCE) directory. This approach may be especially beneficial for small plans lacking the technical resources or expertise to manage the complex infrastructure needed for data exchange.

Will your plan make the 2027 API deadline?
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to improve communication around approvals and denials of prior authorizations (PAs) through data exchange practices. Payers are required to implement an API that can identify documentation requirements for a PA approval and communicate whether a payer approves or denies the request. Payers are also required to implement Provider Access APIs, to facilitate interoperability between payers and providers, as well as Payer-to-Payer APIs for data sharing across health plans.

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