Discover the payer's Patient Access API endpoint; CMS-regulated payers must publish their FHIR R4 base URL and SMART configuration—look for it in their developer portal or via the CMS endpoint directory.
Register your application with the payer's developer portal, requesting SMART scopes aligned with CARIN Blue Button IG (e.g. patient/ExplanationOfBenefit.read, patient/Coverage.read, patient/Patient.read).
Implement the SMART on FHIR standalone launch flow so members can authenticate with their health plan credentials and grant your app access.
After obtaining a token, retrieve ExplanationOfBenefit resources for claims history, Coverage for current plan details, and Patient for demographic data.
Handle the CARIN BB profile-specific extensions on ExplanationOfBenefit (e.g. inNetworkProvider, adjudicationCategory) when parsing claim line items.
For provider-facing workflows, explore the Da Vinci Payer Data Exchange (PDex) and Prior Authorization Support (PAS) IGs which use different resource types and flows.
Known gotchas
Payer implementations vary in completeness even within the CMS mandate; some may return minimal data or require additional credentialing steps beyond the standard OAuth flow.
Claims data reflects billing codes, not clinical diagnoses—ICD-10 codes on claims are assigned for billing purposes and may not accurately represent a member's actual conditions.
Third-party app access to payer data is governed by the member's authorization; you must provide a clear privacy policy and data use disclosure as required by the CMS rule.
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp