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Interoperability Provider Access API

The Provider Access Application Programming Interface (API) allows you to securely request and receive electronic data about your patients who are covered by one of our plans^1,2.

This data offers in-network contracted providers a more complete picture of your patients' health to help you better coordinate their care and reduce administrative tasks.

Through the API, you’ll be able to access:

Claims and encounter data: Includes information from previous or concurrent insurers for dates of service on or after January 1, 2016 as applicable. Cost-sharing information is excluded.
Clinical data: Defined by the United States Core Data for Interoperability (USCDI), PDex Prior Authorization Profile, and CARIN Consumer Directed Payer Data Exchange IG Non-Financial (Basis) Profiles.
Prior authorization information: For all services, except medications.

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How to connect and access data

Your electronic health record (EHR) or electronic medical record (EMR) systems need to be connected to our API to request and receive secure patient data electronically.

To get started, your Information Technology team may need to do this set up. Share this Developer Portal with them for technical specifications and implementation guides:

Blue Cross Blue Shield of Massachusetts Developer Portal

Patient attribution

Health information is shared only with the in-network providers who are actively involved in the member’s care to safeguard their privacy. We will only share data when we've verified this treatment relationship. After conneting to the API, you will be able to view secure data for patients if:

We have received a dental, medical, pharmacy, or vision claim (EyeMed) for the member with your NPI (or your organization’s NPI) in the last 60 days (from the date of the request). If there are no qualifying claims, you won't see data for the member.
The member allows data-sharing (has not opted out).

Member control and privacy

Members have access to their information through a Patient Access API. They can opt out of us sharing data with their providers or other health plans at any time. They can manage their preferences online or by calling Member Service at the number listed on their ID card.

Learn more by going to MyBlue.

FAQs

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What is an API?

An API is a set of rules or protocols that enable software applications to talk with each other and exchange data, features, or other functionality.

Is the API secure?

We follow HIPPA and other interoperability standards to protect data and member privacy.

How often will the data be updated

It's refreshed daily.

Resources

Complies with the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), a federal mandate designed to improve the secure electronic exchange of health information between payers, providers, and patients to streamline care coordination.
The Provider Access APIs provide information about Blue Cross Blue Shield of Massachusetts commercial and Medicare Advantage members. Does not apply to Federal Employee Program members.