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Certified Payer APIs

Netsmart's Certified Payer APIs enable health plans, insurance companies, and managed care organizations to securely share member data and provider directory information in compliance with federal regulations including the CMS Interoperability Rules and 21st Century Cures Act. These FHIR R4-compliant APIs support modern healthcare workflows while ensuring data security and member privacy.

Overview​

Our Payer APIs are designed for health insurance organizations, managed care entities, and their authorized partners. These APIs facilitate secure data exchange between payer systems, member-facing applications, provider networks, and healthcare stakeholders.

API Types​

Patient Access API​

Enables health plan members to access their own health and coverage information through member-facing applications. Supports OAuth 2.0 authorization code flow with member consent.

Key Features:

  • Member-controlled data access
  • SMART on FHIR launch patterns
  • Comprehensive health and coverage records
  • Claims and benefits information

View Patient Access API Documentation

System Access API​

Provides system-to-system integration capabilities for payer applications, including bulk data export for population health management and regulatory reporting.

Key Features:

  • Backend system authentication
  • Bulk FHIR data export
  • Automated data synchronization
  • Population health analytics support

View System Access API Documentation

Provider Directory API​

Offers searchable provider directory services for health plan networks, enabling members and providers to find in-network healthcare services and practitioners.

Key Features:

  • Comprehensive provider search
  • Network and plan-specific filtering
  • Real-time provider information
  • Location and service-based queries

View Provider Directory API Documentation

Supported FHIR Resources​

Our Payer APIs support a comprehensive set of FHIR R4 resources based on US Core 6.1.0 and DaVinci Implementation Guides:

CategoryResources
BasePatient, Practitioner, Organization, Location, RelatedPerson
ClinicalAllergyIntolerance, Condition, Procedure, Observation, DiagnosticReport, Immunization, Specimen, MedicationRequest, MedicationDispense
WorkflowEncounter, EpisodeOfCare, ServiceRequest, CarePlan, CareTeam
FinancialCoverage, ExplanationOfBenefit
SpecializedDevice, DocumentReference, Binary, Group, Provenance
DirectoryHealthcareService, InsurancePlan, Endpoint, OrganizationAffiliation, PractitionerRole

Implementation Standards​

Our Payer APIs implement multiple FHIR Implementation Guides:

Authentication & Security​

Patient Access​

  • OAuth 2.0 Authorization Code Flow
  • SMART on FHIR launch patterns
  • Member consent and authorization
  • PKCE (Proof Key for Code Exchange) support

System Access​

  • OAuth 2.0 Client Credentials Grant
  • Private Key JWT authentication
  • System-level scopes and permissions
  • Bulk data export capabilities

Provider Directory​

  • Public access for basic directory searches
  • Optional authentication for enhanced features
  • Rate limiting and usage monitoring

Getting Started​

  1. Review Prerequisites - Ensure you have CareConnect tenant access and API credentials
  2. Choose Your API Type - Select Patient Access, System Access, or Provider Directory based on your use case
  3. Set Up Authentication - Configure OAuth 2.0 flows for your application (if required)
  4. Explore Resources - Review supported FHIR resources and operations
  5. Test Integration - Use preview environments before production deployment

Environment Information​

Production Environment​

  • Base URL: https://fhir.netsmartcloud.com/payer/
  • Patient Access: /patient-access/v2/{tenant-id}
  • System Access: /system-access/v2/{tenant-id}
  • Provider Directory: /provider-directory/v2/{tenant-id}

Preview Environment​

  • Base URL: https://fhirtest.netsmartcloud.com/payer/
  • Patient Access: /patient-access/v2/{tenant-id}
  • System Access: /system-access/v2/{tenant-id}
  • Provider Directory: /provider-directory/v2/{tenant-id}

Regulatory Compliance​

These APIs are certified to meet federal healthcare interoperability requirements:

  • CMS Interoperability Rules - Payer data sharing and member access requirements
  • 21st Century Cures Act - Member access to electronic health information
  • ONC Health IT Certification - Standardized API criteria compliance
  • HIPAA Security - Protected health information safeguards

Use Cases​

Patient Access API​

  • Member portal integrations
  • Mobile health applications for members
  • Personal health record systems
  • Benefits and claims tracking applications

System Access API​

  • Payer-to-payer data exchange
  • Population health management
  • Quality measure reporting
  • Risk adjustment and analytics platforms

Provider Directory API​

  • Member-facing provider search tools
  • Provider network management
  • Referral and care coordination systems
  • Third-party directory services

Support Resources​

  • Authentication Guide - OAuth 2.0 implementation details
  • Tutorials - Step-by-step integration guides
  • Technical Support - Contact Netsmart for integration assistance

Next Steps​

Ready to integrate? Choose your API type and follow the detailed documentation:

Each API includes comprehensive resource documentation, authentication guides, and practical examples to help you build successful healthcare integrations.