Overview
The Trusted Exchange Framework and Common Agreement (TEFCA) was authorized by the 21st Century Cures Act and implemented by the Office of the National Coordinator for Health Information Technology (ONC). Its purpose is to connect the dozens of regional and national health information networks that previously operated in isolation, so that a clinician or payer connected to any participating network can request and receive data from any other network through a standard legal and technical fabric.
The framework operates through a tiered structure. The Common Agreement is the master contract that governs all participants and is designed by the Recognized Coordinating Entity (The Sequoia Project serves that role). Qualified Health Information Networks (QHINs) are the top-tier exchanges that sign the Common Agreement, meet security and technical requirements, and connect to each other. Participants — hospitals, health systems, EHR vendors, payers, public-health agencies — join one or more QHINs and inherit the ability to exchange data across all QHINs through that single connection. Sub-participants (individual clinics, providers) connect via their upstream Participants.
TEFCA supports six Exchange Purposes at launch: Treatment, Payment, Healthcare Operations, Public Health, Government Benefits Determination, and Individual Access Services (the mechanism for patients to request their own records under HIPAA). Future phases extend to additional purposes including quality measurement and research.
Operationally, TEFCA's significance for RCM is substantial. Eligibility and benefits lookups can pull real-time demographic and coverage information through TEFCA exchange fabric. Prior authorization APIs (CMS-0057-F mandate) ride on the same TEFCA-compatible FHIR infrastructure. Provider directory queries, records for claims adjudication, and attachments for appeals all benefit from standardized exchange rather than bespoke point-to-point integrations. Payers in particular gain chart-retrieval efficiency — HEDIS and risk-adjustment chart abstraction programs historically required armies of vendors; TEFCA + Bulk FHIR offers a standards-based alternative.
Key technical standards underlying TEFCA include HL7 FHIR R4 (the primary API standard), US Core Implementation Guide, IHE XCA for document exchange, and SMART on FHIR for authentication. QHINs must support both the legacy document-query model (CCDA-based, for continuity with pre-TEFCA networks) and FHIR APIs. Over time, the expectation is for FHIR to become the primary exchange mechanism as ONC's HTI-1 final rule mandates US Core FHIR support across certified EHRs.
For a health system, the strategic decision is which QHIN to join. Candidates include eHealth Exchange, Epic's Nexus, CommonWell (operated by Carequality), Kno2, and others. Selection criteria include existing vendor relationships, network reach to the system's referral partners, cost structure, and support for use cases beyond Treatment. Most large systems connect to multiple QHINs to minimize reach gaps during the early years of network consolidation.
Industry benchmark
ONC TEFCA Common Agreement v1.1 (2024). Designated QHINs published on HealthIT.gov. Industry reference: QHIN-to-QHIN live exchange began 2024; production volumes grew rapidly through 2025. CMS-0057-F Interoperability and Prior Authorization Final Rule requires FHIR APIs across impacted payers.
Worked example
A multi-state health system operates 14 hospitals across three regions, each previously connected to a different regional HIE (plus Carequality for national reach). Post-TEFCA, the system connects to a single QHIN and gains query access to the full connected universe. Chart-retrieval for HEDIS chart-chase drops from 60 days per chart (manual fax + follow-up) to 5 days per chart average via FHIR Bulk. Annual HEDIS chart-review vendor cost drops 38%.
Frequently asked questions — TEFCA (Trusted Exchange Framework and Common Agreement)
Is TEFCA mandatory?
No, TEFCA participation is voluntary. However, CMS and private payer contracts increasingly reference TEFCA-compatible exchange as a preferred channel, and CMS's Interoperability and Prior Authorization Final Rule effectively requires payers to support FHIR APIs compatible with TEFCA infrastructure.
How does TEFCA differ from Carequality?
Carequality was the pre-TEFCA interoperability framework used by many networks (including Epic's Nexus and CommonWell). TEFCA supersedes and subsumes prior frameworks: Carequality-connected networks are becoming QHINs or connecting through QHINs, and Carequality governance is being harmonized into TEFCA Common Agreement.
What does TEFCA cost?
Costs flow through the QHIN tier — QHINs charge Participants; Participants may charge Sub-participants. Public pricing is limited, but early-market Participant fees typically run in the $50K–$500K range per year depending on volume. TCO is often offset by consolidation of existing HIE fees.
Can TEFCA be used for prior authorization?
Yes. TEFCA's Exchange Purposes explicitly cover Payment and Healthcare Operations, which include PA workflows. FHIR-based PA APIs (PAS, CRD, DTR) under CMS-0057-F ride on TEFCA-compatible infrastructure, enabling cross-QHIN PA document exchange by 2027.
Disclaimer
This glossary entry is operational reference for revenue-cycle and medical-billing professionals. It is not legal, clinical, or contractual advice. Industry benchmarks cite named public sources where available; always verify against the current guidance from the authority body before relying on a number in a contract, policy, or compliance filing.