Healthcare · Interoperability
Interoperability & Data Standardization
Overview
Worked on payer interoperability programs driven by the CMS Interoperability and Patient Access final rule (CMS-9115-F) and the Interoperability and Prior Authorization final rule (CMS-0057-F), which require payers to expose claims, clinical, and prior-authorization data through standards-based FHIR APIs.
The core of the work was data standardization: developing standard data models (SAMs) that map heterogeneous source data — claims, enrollment, provider, and clinical feeds arriving in every format from EDI to HL7 to flat files — into consistent, interoperable structures that downstream FHIR resources and analytics can rely on.
A major component was interoperability requirements and gap analysis: taking what the regulations require, comparing it element-by-element against what actually exists in a payer's current data, and producing concrete remediation plans — which fields are missing, which need transformation or code-set mapping (ICD, CPT, LOINC, NDC), and which source systems must be onboarded to reach compliance.
Technical Implementation
Regulatory Requirements Mapping
Break down CMS-9115-F (Patient Access API, provider directory) and CMS-0057-F (prior authorization APIs and timelines) into concrete data-element requirements per API and FHIR resource.
Gap Analysis Against Existing Data
Compare required elements against the payer's actual source data — element by element — classifying each as available, transformable, or missing, and identifying the source systems needed to fill gaps.
Standard Data Model (SAM) Development
Design and build standard data models that normalize claims, enrollment, provider, and clinical data into consistent structures, with code-set mapping (ICD-10, CPT, LOINC, NDC) applied at the model boundary.
Remediation & Compliance Roadmap
Deliver prioritized remediation plans — transformations to build, feeds to onboard, mappings to maintain — so the payer reaches API compliance on regulatory timelines.