The Opala Provider
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The CMS Interoperability and Patient Access final rule requires MA organizations, Medicaid FFS programs, CHIP FFS programs, Medicaid managed care plans, and CHIP managed care entities to make provider directory information publicly available via a FHIR-based Provider Directory API.
Provider directories play a key role in enabling the identification of individual providers and provider organizations within a network. The Provider Directory API enables a member to use a third-party application to access information about in-network providers and provider organizations. The Provider Directory API is an open-access API and does not require authentication to access the data.
Opala's Provider Directory API supports the Da Vinci PDEX Plan-Net standard for search and retrieval, based on FHIR R4. The provider directory uses a push service to send new records and updates to the FHIR Repository. This documentation assumes that the developer is familiar with the Da Vinci PDEX implementation guide for a provider directory.
Use this URL to request data from Opala's Provider Directory API:
Note. The legacy URL for Opala's Provider directory will remain accessible through 2023. To request data from the Provider Directory using the legacy URL use:
The PDEX Payer Network (a.k.a., Plan-Net) Implementation Guide is, conceptually, based on the Validated Healthcare Directory Implementation Guide (VHDir IG), an international standard, which in turn is based on FHIR Version 4.0. The primary changes made by Plan-Net are:
Note: Alignment with VhDir is maintained by adapting VhDir content where possible.
The Plan-Net IG was written for a US audience, and describes resources from US Core STU 3.1 where available (Practitioner, Organization, Location), and from R4 (OrganizationAffiliation, PractitionerRole, HealthCareService, Endpoint) otherwise.
The Network profile is based on USCore Organization, since there is no contradiction between the USCore profile and the Plan-Net requirements; however, the NPI and CLIA identifier types, which are Must-Support, are intended for provider organizations only and are not expected to be populated for other organization types.
Note: The PractitionerRole profile from US Core was not used because it is overly constrained for use in a Provider Directory based on Payer information.
The Provider Directory enables you to find a practitioner or organization. This section describes the use cases and search expectations for the Provider Directory.
Note: When searching for a practitioner by region using a postal code, Opala recommends you do not use the zip+4 format. Including the +4 suffix limits the results to a very specific area and is much less useful for finding a practioner within a postal code area.
_revinclude parameters request that search results include additional resources related to the resources directly matching the query (i.e., the primary results). Use these parameters to retrieve additional resources with a single request rather than making a series of requests for the resources separately.
_includeparameter adds resources and resource versions referenced by the primary results.
_revincludeparameter adds resources that reference the primary results.
The Opala Provider Directory supports the
_revinclude parameters using the following syntax:
GET [baseUrl]/[resourceType]?[optional parameters]&[_include|_revinclude]=[parameters]
There are two methods for querying Provider-type FHIR Resources.