What to Know About CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F): Quick Facts & Next Steps

For healthcare organizations, CMS-0057-F outlines the modern healthcare system and offers opportunities to improve care and utilization management

In the last couple of years, the Centers for Medicare & Medicaid Services (CMS) have been making strides to increase health data exchange, as well as improve and expand access to care. On January 17, CMS finalized its interoperability and prior authorization rule. The rule applies to Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs).

These plan requirements will begin primarily in 2026, but many healthcare organizations have already started working on them per the rule announcement set in the last couple of years.

Below we dive into:

  1.  The requirements these organizations will have to meet
  2. The opportunities and benefits CMS-0057-F rule offers
  3. The next-step actions impacted health plans and healthcare organizations need to take (Feel free to skip down to the bottom for these steps if you’re already aware of the rule’s requirements)

What are the Final Requirements of CMS-0057-F?

All of the final requirements listed in CMS-0057-F are focused on improving prior authorization processes, reducing the burden on patients, providers, and payers, and ultimately helping to lower healthcare costs for all (currently CMS estimates $15 billion in savings over 10 years).

In a simple statement: CMS-0057-F requires healthcare payors to streamline prior authorization processes, complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule that added continuity of care requirements and works to reduce disruptions for plan beneficiaries.

CMS-0057-F Healthcare Interoperability Requirements

  1. Implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API) [Prior Authorization API]
  2. Be compliant with new API requirements (still in progress, and “CMS is delaying the dates for compliance with the API policies from generally January 1, 2026, to January 1, 2027.”)
  3. Expand current Patient Access API to include information about prior authorizations (begins January 2027)
  4. Implement a Provider Access API so providers can retrieve patients’ claims, encounters, clinical, and prior authorization data (Good thing HELIOS® has a dedicated provider portal already)
  5. Use a Payer-to-Payer FHIR® API to exchange most of the same data when a patient moves between payers or has multiple concurrent payers (requires patient permission)

CMS-0057-F Healthcare Prior Authorization Requirements

  1. Send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests
  2. Send prior authorization decisions within seven calendar days for standard (i.e., non-urgent) requests for medical items and services
  3. Include specific reasoning for denying prior authorization requests to help facilitate either a resubmission or appeal
  4. Publicly report prior authorization metrics (see here for the format they’ll need to be similar to)
  5. The New Electronic Prior Authorization measure will require reporting the use of payors’ Prior Authorization APIs to submit an electronic prior authorization request (applies to eligible clinicians under the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category and eligible hospitals and critical access hospitals (CAHs) in the Medicare Promoting Interoperability Program)

What Opportunities Does CMS-0057-F Create for Businesses and the Healthcare Ecosystem?

Healthcare business opportunities with CMS-0057-F

  1. Faster, more streamlined authorizations
  2. Greater health data flow for increased care collaboration and coordination among providers, payors, and the patients/plan members they serve
  3.  Reduced friction with healthcare providers
  4. Streamline and automate prior authorization processes (reviews, appeals, authorizations/approvals, and grievances)
  5. Reduced risk of human error (and less stress on staff)
  6. More efficient data management, without duplication of effort across teams
  7. Higher plan satisfaction ratings
  8. Cost-savings
  9. Reduced staff burnout and increased productivity

Impact of CMS-0057-F on the broader healthcare ecosystem

  1. Shorten wait times for health plan members to receive the care services they need (The new rule will cut some prior authorization request times in half!)
  2. Will be easier for healthcare practitioners to provide the necessary care people need
  3. Improved health outcomes
  4. Better healthcare experiences
  5. More accurate care decisions
  6. More expedient care delivery
  7. Reduce administrative workload on staff and reduce burnout
  8. Increase the amount of time practitioners can spend with patients to provide more direct care and prevent avoidable delays

The 3 Practical Next-Steps for Healthcare Organizations

The new CMS ruling offers several opportunities that benefit payors, providers, and health plan members alike. But for organizations unsure of what steps to take next, see below for a quick list of practical actions you can take now to begin preparing for achieving compliance and maximizing the opportunistic value for your business and members.

Action 1: Implement FHIR® Now

One of the easiest first steps impacted payors can take is to implement FHIR® right away. While CMS requires payors to “implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API)” many payors may be hesitant to deal with yet another technology solution that their IT team has to learn to use, update and handle.

This is exactly why HELIOShub was designed to be plug-and-play. Unlike other FHIR® solutions, HELIOShub is easy for healthcare payors to use and doesn’t require IT specialization. Moreover, HELIOShub allows payors to seamlessly convert data into FHIR®-compatible formats and share newly converted data to other enterprise platforms for seamless data uniformity, care continuity, and greater lifetime value.

The first FHIR® Integration Platform as a Service (FiPaaS), HELIOShub was designed to break down the barriers to data interoperability and FHIR® adoption quickly and at scale. HELIOShub has even been proven to reduce integration times by 65% or more. And because HELIOS solutions are continually evolving, as CMS continues to finalize the API requirements for increasing data exchange, VirtualHealth will be continuing to update the solution to ensure HELIOShub users are properly supported.

WHY THIS MATTERS: For healthcare payors impacted by CMS’s new rule, this means they can not only work on becoming compliant with the new interoperability standards but see immediate value in reducing time spent on data interoperability and instead spend it on improving care experiences. Moreover, HELIOShub will help give organizations more confidence who are worried about how the Department of Health and Human Services (HHS) will use enforcement discretion for the Health Insurance Portability and Accountability Act of 1996 (HIPAA) X12 278 prior authorization transaction standard.

Learn about HELIOShub’s unique features (including a full library of APIs and FHIR® store) here >

 

Action 2: Upgrade your utilization management solution for one that streamlines and automates prior authorization

Older utilization management solutions may not be able to keep up with the new CMS rule. Instead of struggling and wasting dollars trying to make an existing outdated system work, now is a smart time to make a change and update your utilization management solution. (Ideally, one that integrates with your care management tool as well.)

HELIOSum unifies providers, care managers, and utilization management (UM) teams on a single platform to revolutionize UM activities across the board. HELIOSum can help payors streamline authorizations, drive efficiencies, gain accuracy and confidence, and meet UM goals and requirements. An integrated partner ecosystem includes Edifecs, Change Healthcare (InterQual), and MCG among others, so payors can easily access and leverage clinical guidelines for enhanced accuracy and compliance, automate prior authorizations, and enable streamlined electronic prior authorizations and appeals.

Discover more about HELIOSum here >
Watch a quick overview of HELIOSum here >

Action 3: Determine if your current utilization management solution can supply the necessary metrics you’ll need to supply for prior authorization and claims

Many payors are still using outdated and inefficient utilization management solutions. The final action we recommend taking now is to do a hard evaluation of your solution and see if it can provide the metrics you’ll need to report on.

If not, it’s probably time to start shopping around and choose one that can better support your program for the short- and long-term.

We already know that interoperability and prior authorization have been thorns in the side of health organizations all over. Lack of effective data results in a lack of clarity and transparency that often leads to costly miscommunications and errors that are detrimental to both health plan members and payor-provider relationships. This impedes clinical work by providers and results in inadequate or erroneous care decisions, fragmented care services, and poorer health outcomes.

Why Do the New CMS-0057-F Requirements Matter?

Moreover, on the prior authorization front, a recent survey of physicians and health care staff from the American Medical Association (AMA) found that 25% reported that prior authorization had led to a patient’s hospitalization; 46% reported that prior authorization had led to immediate care and/or ER visits, and 33% reported that prior authorization had led to a serious adverse event for a patient in their care.

The new CMS rule for prior authorization and interoperability will help create a connected healthcare ecosystem that allows for collaborative communication between providers, payors and patients/members, ultimately leading to both more accurate, effective care experiences and more efficient and cost-friendly processes for healthcare businesses.

 

 

 

 

 

 

HL7, FHIR and the FHIR® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.

 

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