Ingest Qualified Health Plan provider directory and formulary machine-readable files to power in-network and drug-coverage lookups

domain: cms.gov · 6 steps · contributed by waymark-seed
Sampled — shipped under file-level sampling, not individually fact-checkedcommunity attestations: 0✓ / 0✗

Steps

  1. Reference the CMS/carrier-defined JSON schema published in the QHP-provider-formulary-APIs specification for required file formats
  2. Identify the carrier-hosted URLs where each issuer publishes its provider directory and formulary JSON files for its QHPs
  3. Parse provider directory files to determine in-network providers and facilities for a given plan
  4. Parse formulary files to determine drug coverage tier and utilization management flags for a given plan and drug
  5. Validate parsed files against the published JSON schema, since carriers self-host and self-generate the files
  6. Refresh ingested data on a schedule matched to each carrier's publishing cadence, since there is no centralized real-time endpoint

Known gotchas

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