Provider Access API

The Da Vinci PDex Provider Access API lets an in-network provider with a treatment relationship to a payer's member pull that member's clinical, claims, encounter, and prior-authorization data in bulk. Established by CMS-0057-F, effective January 1, 2027.

What Payerbox covers

• PDex Implementation Guide preconfigured.
• $provider-member-match and $davinci-data-export operations available on the Interop bundle.
• Plugs into the payer's existing attribution roster — accepts Group ingestion or an equivalent lookup feed.
• Member opt-out filtering applied before any Provider Access response.
• Audit logging per provider request, scoped to the requesting provider.

Caller and auth

See API Reference / Authentication.

Two paths to the data

PDex keeps two patterns for delivering Provider Access data. For CMS-0057-F conformance the IG recommends v2 (Attestation). v1 is retained primarily for value-based-care attribution workflows.

v1 — Payer-attributed Group export

The payer maintains an attribution roster mapping each in-network provider to the members the payer considers attributed to that provider, exposed as a Group resource per provider. The provider calls $davinci-data-export against that Group:

POST <base>/fhir/Group/<group-id>/$davinci-data-export
Prefer: respond-async

No per-call match step — the roster is the gating mechanism, augmented by the member opt-out list.

v2 — Provider-attested member match

The provider asserts the treatment relationship at request time, the payer matches the provider's patient list against enrolled members, and the provider then exports the matched Group.

1. Match members. Submit a batch of patient demographics, coverage references, and a treatment-relationship attestation to $provider-member-match:

   POST <base>/fhir/Group/$provider-member-match
   Prefer: respond-async
   

   The payer returns up to three Group resources in the response:

   • MatchedMembers — members successfully matched and whose treatment attestation has been verified
   • NonMatchedMembers — members the payer could not match, or whose attestation could not be verified
   • ConsentConstrainedMembers — matched members who have opted out of provider data sharing (the payer may suppress this group for privacy)

2. Export data. Use the MatchedMembers Group id with $davinci-data-export:

   POST <base>/fhir/Group/<matched-members-group-id>/$davinci-data-export
   Prefer: respond-async
   

   The async pattern follows FHIR Bulk Data semantics: poll Content-Location, retrieve NDJSON manifests when complete.

Both $provider-member-match and $davinci-data-export are always asynchronous — kick-off returns 202 Accepted with a Content-Location header; the client polls until the result is ready.

$davinci-data-export is defined in the Da Vinci ATR IG and referenced by PDex; it is a profiled extension of FHIR Bulk Data Export and is the only bulk entry point for Provider Access.

Consent model

CMS-0057-F prescribes opt-out for Provider Access. Default is share-on; a member who opts out is removed from the data response for all in-network providers — PDex 2.1.0 frames the opt-out as all-or-nothing, not per-provider. The member can opt out and reverse the choice at any time.

Opt-out is captured by the payer and surfaced to Payerbox so the API filters out opted-out members before responding, regardless of whether v1 or v2 is used.

Data scope

Same data set Provider Access shares with Patient Access, excluding provider remittances and enrollee cost-sharing.

Service date floor: January 1, 2016.

Operations

$provider-member-match

v2 only. The provider submits one or more MemberBundle parameters — each carrying a MemberPatient (demographics), CoverageToMatch, and a Consent (treatment-relationship attestation). The Consent must conform to the HRex Consent profile — meta.profile, provision.period, source, and two actors (performer for the member's payer and IRCP recipient for the requesting provider) are required. The kick-off returns 202 Accepted with a Content-Location; when polled, the manifest points at an ndjson Parameters resource holding up to three inline Group resources (MatchedMembers, NonMatchedMembers, ConsentConstrainedMembers).

POST <base>/fhir/Group/$provider-member-match
Authorization: Bearer <access-token>
Content-Type: application/fhir+json
Prefer: respond-async

{
  "resourceType": "Parameters",
  "parameter": [{
    "name": "MemberBundle",
    "part": [
      {"name": "MemberPatient", "resource": {
        "resourceType": "Patient",
        "name": [{"family": "Smith", "given": ["John"]}],
        "gender": "male", "birthDate": "1970-05-15"
      }},
      {"name": "CoverageToMatch", "resource": {
        "resourceType": "Coverage", "status": "active",
        "beneficiary": {"reference": "Patient/patient-1"},
        "payor": [{"reference": "Organization/payer-org-1"}]
      }},
      {"name": "Consent", "resource": {
        "resourceType": "Consent",
        "meta": {"profile": ["http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-consent"]},
        "status": "active",
        "scope": {"coding": [{"system": "http://terminology.hl7.org/CodeSystem/consentscope", "code": "patient-privacy"}]},
        "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "IDSCL"}]}],
        "patient": {"reference": "Patient/patient-1"},
        "performer": [{"reference": "Patient/patient-1"}],
        "sourceReference": {"reference": "http://example.org/DocumentReference/consent-doc-1"},
        "policy": [{"uri": "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition-hrex-consent.html#regular"}],
        "provision": {
          "type": "permit",
          "period": {"start": "2026-01-01", "end": "2027-01-01"},
          "actor": [
            {
              "role": {"coding": [{"system": "http://terminology.hl7.org/CodeSystem/provenance-participant-type", "code": "performer"}]},
              "reference": {"identifier": {"system": "http://hl7.org/fhir/sid/us-npi", "value": "9876543210"}, "display": "Member health plan"}
            },
            {
              "role": {"coding": [{"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "IRCP"}]},
              "reference": {"identifier": {"system": "http://hl7.org/fhir/sid/us-npi", "value": "0123456789"}, "display": "Requesting provider"}
            }
          ],
          "action": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/consentaction", "code": "disclose"}]}]
        }
      }}
    ]
  }]
}

HTTP/1.1 202 Accepted
Content-Location: <base>/fhir/Group/$provider-member-match-status/<task-id>

Full parameter table, status / output / cancel endpoints, and all response variants: $provider-member-match reference.

$davinci-data-export

v1 and v2. Async bulk export against a Group of attributed (v1) or matched (v2) members. Defined in the Da Vinci ATR IG and referenced by PDex.

POST <base>/fhir/Group/<group-id>/$davinci-data-export
Authorization: Bearer <access-token>
Content-Type: application/fhir+json
Prefer: respond-async

{
  "resourceType": "Parameters",
  "parameter": [
    {"name": "exportType", "valueCanonical": "hl7.fhir.us.davinci-pdex#provider-download"},
    {"name": "_type",      "valueString":    "Patient,Coverage,ExplanationOfBenefit"}
  ]
}

HTTP/1.1 202 Accepted
Content-Location: <base>/fhir/$export-status/<job-id>

Full parameter table (exportType allowed values, _since, _until, _type, _typeFilter, _outputFormat, patient), poll / output / cancel endpoints, and error responses: $davinci-data-export reference.