PayerBridge.AI — Payer Interoperability

Scope

Four payer-interoperability API families

The regulatory foundation is CMS-9115-F (2020, final), CMS-0057-F (2024, final), and CMS-0062-P (2026, proposed — tracked, never treated as a mandate). Impacted payers include Medicare Advantage, state Medicaid and CHIP with managed care, and QHP issuers on the Federally Facilitated Exchanges.

Patient Access API

CARIN Blue Button

Patient-authorized retrieval of claims, encounters, clinical data and formulary.

kt: patient-access-api

CMS-9115-F

Provider Access API

Da Vinci PDex

Provider retrieval of member data with attribution and patient opt-out.

kt: provider-access-api

CMS-0057-F

Payer-to-Payer API

Da Vinci PDex

Member-authorized exchange when a member changes or adds a payer (opt-in).

kt: payer-to-payer-api

CMS-0057-F

Prior Authorization API

Da Vinci CRD + DTR + PAS

Coverage requirements discovery, documentation rules and PA submission. Human decides.

kt: prior-authorization-api

CMS-0057-F

Evidence

Readiness matrix

Honest Phase-1 states. A requirement advances NOT ASSESSED → MAPPED → DESIGNED → IMPLEMENTED → TESTED → EVIDENCED → APPROVED. Only a named human approver can set APPROVED; no implementation status alone is shown as "compliant".

Requirement	Authority	Owner	Status	Evidence	Gap / note
Patient Access API	CMS-9115-F	Mario	MAPPED	kt: patient-access-api	Not implemented; enforcement baseline 2021-07-01
Provider Access API	CMS-0057-F	Mario	MAPPED	kt: provider-access-api	API compliance date 2027-01-01
Payer-to-Payer API	CMS-0057-F	Mario	MAPPED	kt: payer-to-payer-api	Opt-in + lookback window (verify)
Prior Authorization API (CRD/DTR/PAS)	CMS-0057-F	Mario	DESIGNED	kt: prior-authorization-api	PA decision timeframes begin 2026
PA decision timeframes (72h expedited / 7 day standard)	CMS-0057-F	Bill	MAPPED	kt: cms-0057-f	Policy-engine, not AI; human authority
Public PA metrics reporting	CMS-0057-F	Bill	NOT ASSESSED	-	First report window 2026-03-31 (verify)
Drug prior authorization standards	CMS-0062-P (PROPOSED)	Bill	NOT ASSESSED	kt: cms-0062-p-proposed	Proposed rule — track, do not implement
Identity / OAuth / SMART / scopes	HL7 SMART	Mario	DESIGNED	kt: identity-and-access-management	Deterministic trust services
Consent / opt state / revocation	CMS-0057-F	Mario	DESIGNED	kt: consent-opt-in-and-opt-out	Differs per API
Audit + provenance (immutable)	HL7 FHIR	Ryo	MAPPED	kt: audit-provenance-and-evidence	AuditEvent + Provenance

Design

Reference architecture

Every request runs the same deterministic spine; AI never sits in the decision path.

API + Identity Edge

TLS · API gateway · OAuth 2.0 · OIDC · SMART App Launch · rate limits

Deterministic Trust Services

client registration · token/scopes · consent/opt state · attribution · purpose of use · policy enforcement · audit · provenance · revocation

FHIR API Plane

Patient Access (CARIN BB) · Provider Access (PDex) · Payer-to-Payer (PDex) · Prior Authorization (CRD + DTR + PAS)

Normalization + Payer Data

FHIR resources · USCDI mapping · claims/encounters · coverage/policy · authorization state · terminology · source provenance

CareCompile Intelligence

PayerBridge KT/KTW · scoped RAG · rule crosswalk · evidence dashboard · human review — no autonomous coverage decisions

REQUEST -> authenticate client -> authorize scopes and purpose -> resolve patient/member and relationship -> evaluate consent or opt state -> execute deterministic API workflow -> attach provenance -> write immutable audit event -> return standards-conformant response -> expose evidence without exposing PHI

Timeline

Compliance dates

Dates marked "(verify)" resolve to the controlling CMS rule text before they are relied upon.

When	Rule	Milestone
2021-07-01	CMS-9115-F	Patient Access API and Provider Directory API enforcement baseline
2026-01-01	CMS-0057-F	PA decision timeframes (72h expedited / 7 calendar-day standard) and specific denial reasons begin (verify)
2026-03-31	CMS-0057-F	First public prior-authorization metrics reporting window (verify)
2027-01-01	CMS-0057-F	Provider Access, Payer-to-Payer, and Prior Authorization APIs compliance date
PROPOSED	CMS-0062-P	Interoperability standards and prior authorization for drugs — proposed; tracked, not a mandate

Knowledge Tree

PayerBridge KT / KTW — 46 nodes indexed

The scoped knowledge tree grounds every assistant answer. Open the interactive graph: kt-graph.php?scope=payerbridge.

Regulations & Positioning

authoritative-source-policy cms-0057-f cms-0062-p-proposed cms-9115-f compliance-timeline impacted-payers payerbridge scope-and-positioning

Architecture

api-gateway-integration audit-provenance-and-evidence consent-opt-in-and-opt-out data-normalization-and-terminology identity-and-access-management payer-fhir-reference-architecture provider-attribution

API Families

patient-access-api payer-to-payer-api prior-authorization-api provider-access-api

Implementation Guides

bulk-data-access carin-blue-button davinci-crd davinci-dtr davinci-pas davinci-pdex smart-app-launch

Workflows (KTW)

access-denial-and-appeal-workflow compliance-readiness-assessment consent-and-revocation-workflow incident-and-breach-response-workflow ktw-family-router patient-access-workflow payer-to-payer-workflow prior-authorization-workflow provider-access-workflow provider-attribution-workflow

Testing

api-test-evidence authorization-negative-tests fhir-conformance-testing go-live-readiness-gates synthetic-test-personas

Worked Cases (synthetic)

member-changes-payer-case patient-access-case prior-authorization-case provider-treatment-relationship-case

Grounded assistant

Ask PayerBridge.AI

Answers are grounded in the scoped KT and cite exact source nodes. Deterministic services decide; the assistant explains, maps and drafts. Requires an authenticated CareCompile admin session.

PayerBridge.AI assistant synthetic examples only · no PHI

Ask about a CMS rule, an API family, consent/opt state, prior authorization, or a readiness gap.

Dev panel

endpoint/api/payerbridge-stream.php kt scopepayerbridge → payer-interoperability model- provider- sources- tokens- latency-