New interoperability and prior authorization APIs
Blue Cross and Blue Shield of NC (Blue Cross NC) will implement new application programming interfaces by Jan. 1, 2027, to support the secure exchange of information between health plans and providers.
The Centers for Medicare & Medicaid Services Interoperability and Prior Authorization Final Rule, CMS-0057-F, requires Blue Cross NC to implement new application programming interfaces, or APIs, designed to improve healthcare interoperability, support care coordination, and reduce administrative burden.
These capabilities will include a Provider Access API and three Prior Authorization APIs. The APIs will use HL7® FHIR® standards to support secure, automated data exchange between payer and provider systems.
Provider Access API
The Provider Access API will allow authorized participating providers to electronically access certain patient information maintained by Blue Cross NC for patients with whom they have an established treatment relationship.
Information available through the API may include:
- Claims and encounter data
- Clinical data received or maintained by the health plan
- Prior authorization information, including status and decision details when applicable
The Provider Access API is intended to give providers more timely access to relevant patient information, reduce manual record requests, and support better-informed clinical decision-making at the point of care.
Member privacy protections will remain an important part of this capability. Member data will be shared with authorized treating providers by default, but members may opt out at any time. The information available through the API may therefore vary based on a member’s data-sharing preference.
Prior Authorization APIs
Blue Cross NC will also implement three Prior Authorization APIs that supplement existing channels for submitting prior authorization requests. These APIs are intended to support the electronic prior authorization process through providers’ electronic health record, practice management, or other health information technology systems.
The three APIs include:
- Coverage Requirements Discovery API: Helps providers determine whether prior authorization is required.
- Documentation Templates and Rules API: Identifies the information and documentation required for a prior authorization request.
- Prior Authorization Support API: Supports the electronic exchange of prior authorization requests and decisions.
In collaboration with the Blue Cross Blue Shield Association, Blue Cross NC is extending these capabilities across all lines of business, including commercial and Federal Employee Program coverage.
Access and onboarding requirements
Providers, provider systems, and prior authorization coordinators must complete applicable onboarding, registration, authentication, and credential-verification processes before accessing the APIs. Access to information through the Provider Access API will be limited to authorized providers who have a treatment relationship with the member.
What providers can do now
Providers should begin preparing by:
- Reviewing their organization’s interoperability capabilities and FHIR readiness.
- Identifying systems or vendors that may connect to Blue Cross NC APIs.
- Preparing to complete required registration, authentication, and credential-verification processes.
- Ensuring compliance with applicable privacy, security, and data-use requirements.
- Monitoring Blue Cross NC communications for onboarding instructions, technical specifications, and testing opportunities.
Blue Cross NC must implement these APIs by Jan. 1, 2027. Additional onboarding, registration, and technical information will be posted on the Blue Cross NC API access page as it becomes available.
For questions about the APIs or future onboarding activities, email InterOpRegistration@bcbsnc.com.