Onyx Blog
CMS-0057: Bringing Claims and Clinical Data Together to See the Full Member Story
Health plans have never lacked data.
They’ve lacked a complete picture.
Member history is often spread across providers, health plans, and disconnected systems, making it difficult to understand the full care journey when important decisions need to be made.
CMS-0057 begins to change that.
Through Patient Access, Provider Access, and Payer-to-Payer APIs, the rule creates new opportunities to connect claims and clinical data across the healthcare ecosystem, giving health plans access to a more complete view of the member.
In this clip, Mark Scrimshire, Chief Interoperability Officer at Onyx, explains why a more complete member history can help health plans make more informed decisions and identify opportunities to act sooner.
“A more complete member history gives health plans the opportunity to act before a high-cost event occurs.”
Mark Scrimshire, speaking with Availity
Today, health plans may learn about a meaningful change in a member’s health only after a hospitalization, high-cost claim, or other significant event has occurred.
Connecting claims and clinical information can provide more context sooner.
Instead of seeing only the information generated within their own plan, health plans may gain greater visibility into previous coverage, care received from other providers, and broader clinical history.
That perspective can help care management, utilization management, risk adjustment, and other operational teams better understand member needs, manage risk, and recognize opportunities for earlier intervention.
The value of CMS-0057 is not simply that more data becomes available.
It is that current, trusted, and usable information can be brought into the workflows where decisions are made.
But compliant APIs are only part of the equation.
Health plans also need the ability to validate, govern, monitor, and operationalize the information moving through those APIs. Connected data delivers value only when it is reliable and available to the teams that need it.
Successful CMS-0057 programs extend beyond technical compliance.
They establish the data foundation needed to support digital quality, payment integrity, risk adjustment, care management, provider collaboration, and future CMS initiatives.
CMS-0057 creates an opportunity to see more of the member journey. The organizations that realize the greatest value will be the ones that turn that broader view into earlier, more informed action.
Onyx helps health plans build the data foundation that powers continuous compliance—so every new CMS mandate strengthens rather than strains operations.
Our CMS Readiness Check identifies gaps across APIs, data readiness, workflow alignment, vendor handoffs, governance, testing, and operational execution.
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