When Claims and Clinical Data Flow Together, Gaps in Care Close
At Onyx, we believe interoperability should do more than check a regulatory box. It should give payers, providers, and members the information they need to improve care. Recently, our team, in close partnership with a large regional health plan, reached a milestone we’re especially proud of: going live in production with both claims and clinical data compliant with the CMS0057 Advanced Interoperability and Electronic Prior Authorization Mandate.
This wasn’t just a technical achievement. It was the result of months of collaboration, shared problem-solving, and a commitment to building something sustainable for the long term.
Why This Matters
Most interoperability efforts, especially CMS0057 begin with the claims data and clinical data as being the foundation for APIs. Claims are standardized, widely used, and essential for understanding utilization and costs. But claims alone only tell part of a member’s story.
Clinical data including lab results, medications, vitals, and care plans, adds the context providers need to make informed decisions and payers need to support quality programs, risk adjustment, and value-based contracts. Historically, this data has been locked away in multiple systems and formats, making it hard to share and use at scale.
By integrating both claims and clinical data via FHIR APIs, this health plan can now deliver a complete member record across Patient Access, Provider Access, and Payer-to-Payer Exchange under CMS-0057.
What This Enables
With claims and clinical data flowing together in real time, the plan can:
- Support care coordination by giving providers a fuller view of each patient’s history.
- Improve quality measurement with complete data to identify, track, and close gaps in care.
- Advance value-based care by aligning utilization data with clinical outcomes for more effective contracting and population health management.
A Step Forward for Interoperability
Many organizations have implemented claims data exchange. Far fewer have achieved clinical data exchange at production scale, and even fewer have done it in a way that’s built for sustainability.
This implementation is proof of what’s possible when technology and strong customer partnerships come together, meeting CMS-0057 requirements while also creating a foundation for innovation.
Best Practices for Integrating Claims + Clinical Data
From our work on this project, here are a few takeaways for payers preparing to integrate both data types:
- Start with a shared vision — Agree early on what “success” means beyond compliance.
- Build a joint project team — Include clinical, business, and technical leaders from the start.
- Validate data quality early — Address gaps and inconsistencies before scaling.
- Plan for identity resolution — Ensure members are matched accurately to avoid data fragmentation.
- Design for scalability — Build for additional lines of business and APIs from the start.
- Measure real-world impact — Track metrics that matter: quality scores, provider satisfaction, care gap closure.
Looking Ahead
As CMS-0057 deadlines approach, more health plans will be working to bring claims and clinical data online at scale. The experience of this regional health plan shows it can be done — and that collaboration between payer and technology partner is key to success.
At Onyx, we’re proud of what we achieved together and look forward to helping more plans turn compliance into meaningful improvements in care delivery.
Learn more about how we’re helping payers meet the CMS-0057 mandate while driving business value.