Interoperability and Patient Access

Your Health Data, Accessible on Your Terms

Clever Care believes health information should be available when and where members need it. Members can securely view their health information with ease, and with permission, access a more complete picture of their care.

Federal interoperability rules make it easier for members to safely view, download, and share health information using third-party apps. These rules use Application Programming Interfaces (APIs) that help different computer systems connect, enabling members and providers to get information when needed.

What’s available now (2026): Members can use third-party health apps to access claims, encounters, and certain clinical data. Clever Care follows new federal timelines and transparency for prior authorization decisions.

Prior Authorization Timelines & Transparency (effective 2026)

• Decision timeframes: Standard requests within 7 calendar days; expedited requests within 72 hours (non-drug services).
• Denial explanations: Every denial includes a specific reason.
• Annual metrics: PA metrics (volumes, approvals/denials, average decision times) are posted each year.

What’s Coming January 1, 2027

Prior authorization details (non-drug) will be available through the Patient Access API; new Provider Access, Payer-to-Payer, and Prior Authorization APIs will go live.

How It Works

No app can access your data without your permission. Members decide which app to use and what it can see.

• Pick an app
• Connect your Clever Care account inside the app and review the app’s data access request. Sign in and consent to share.
• See your information (typically available no later than one business day after processing) and use the app’s tools to track care.

What Information Can Be Available Through the API

Federal interoperability rules require health plans to share certain information:

• Claims and encounter information including paid and denied claims
• Clinical information, such as conditions, medicines, allergies, and lab results
• Formulary information showing drugs covered by the plan
• Part D drug information, including details about processed claims

Privacy & Security — Choosing an App Wisely

• Review the App’s Privacy Policy — Choose apps that clearly explain data collection, use, storage, and sharing practices.
• Understand Secondary Uses of Your Data — Some apps use information for advertising, research, or analytics.
• Know What Permissions You’re Giving — Check whether an app requests access to device location, contacts, or other non-health information.
• Check Security Features — Look for apps using encryption, access controls, and established privacy frameworks.
• Know How to Revoke Access — Understand how to stop data sharing and request deletion.

Understanding HIPAA and Third-Party Apps

Not every organization or app that collects health information is covered by the Health Insurance Portability and Accountability Act (HIPAA).

Who Is Generally Covered by HIPAA?

HIPAA generally applies to:

• Health plans
• Health care clearinghouses
• Health care providers that conduct certain health care transactions electronically
• Business associates that perform certain services for a HIPAA-covered entity

As a health plan, Clever Care Health Plan is subject to applicable HIPAA privacy and security requirements.

Who May Not Be Covered by HIPAA?

Some third-party apps, websites, wearable-device companies, and other consumer technology companies may not be HIPAA-covered entities or business associates, even if they collect health-related information.

If you choose to share your information with a third-party app, HIPAA protections may not apply to information maintained by that app. Before connecting an app, review its privacy policy and terms of use to understand how your information may be collected, used, stored, and shared.

How to File a Privacy or Security Complaint

U.S. Department of Health & Human Services (HHS) Office for Civil Rights (OCR)

OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules for HIPAA-covered entities and their business associates.

File a complaint online:
https://www.hhs.gov/hipaa/filing-a-complaint/index.html

Federal Trade Commission (FTC)

The FTC helps protect consumers from unfair or deceptive business practices, including certain privacy and security practices involving third-party apps and other companies that may not be subject to HIPAA.

File a complaint online:
https://reportfraud.ftc.gov/

FAQs

What is “interoperability”?
The ability of different systems and apps to securely access, exchange, and use data so members and providers have timely information.

Who is covered by these rules?
Medicare Advantage organizations (like Clever Care for MA/MAPD), Medicaid/CHIP programs, and QHP issuers on FFEs.

Do I have to use a third party app?
No. It’s optional. Members can keep using Clever Care’s portals and standard channels to view information.

When will prior authorization details show in my app?
For non-drug services, impacted payers must expose prior authorization data via the Patient Access API by January 1, 2027.

How quickly does data appear?
CMS expects data to be available no later than one business day after it is received or processed.

Are all third-party health apps covered by HIPAA?
No. Some third-party health apps may not be HIPAA-covered entities or business associates. Before authorizing an app to access your health information, review the app’s privacy policy and terms of use to understand how the app may collect, use, store, and share your information.