Provider Access API
Use Cases
The Provider Access API enables secure and standards-based data exchange to support a variety of use cases that enhance care delivery and coordination. By giving authorized providers timely access to patient data maintained by payers, the API helps close information gaps and promotes more informed, efficient care.
Provider Attribution lists
The core element of Provider Access API is Attribution lists that enable a Provider, Facility or Provider Organization to retrieve data for health plan members that have a current treatment relationship with the provider. Attribution lists are managed by payers and identified by a Provider’s TIN (Tax Identification Number) with attributions to members at Organization or practitioner NPI levels.
Provider organizations can search attribution lists (represented as PDex Groups in FHIR) using TIN search. Provider access to member attribution lists and associated patient data is restricted based on authorized TIN. Group discovery is a TIN based identifier FHIR search on the Group resource, where a successful response is a list of Group(s).
By TIN Identifier System:
GET https://opala.tech/provider-access/premera/v1/fhir-r4/Group?identifier=urn:oid:2.16.840.1.113883.4.4|{tin}
By Coding System Type:
GET https://opala.tech/provider-access/premera/v1/fhir-r4/Group?identifier:of-type=http://terminology.hl7.org/CodeSystem/v2-0203|TAX|{tin}
Bulk Data Export
Provider Access API uses FHIR Bulk Data Export capabilities for providers to make an async request for clinical, encounter, claims and prior authorization data The basic syntax for this request is as follows. Refer the Bulk Export section for more information.
GET https://opala.tech/provider-access/premera/v1/fhir-r4/Group/{group-id}/$export
Claims and Encounter Data
The Member Clinical Data available through the Provider Access API gives authorized providers access to payer-maintained clinical information for attributed members. This includes data such as diagnoses (Condition), lab results (Observation), allergies (AllergyIntolerance), immunizations (Immunization), and more. This helps providers who have active treatment relationship with members get a complete view of the member’s health history.
Prior Authorizations
Prior Authorization data for attributed members are available for export through Opala’s Provider Access API. The API uses ExplanationOfBenefits(EoB) profile created exclusively for prior authorization and suggested for payer data exchange requirements. The data includes status of prior authorizations sourced from payers, adjudication information (with financial info redacted), diagnosis and procedure information.