Health Payers
Stay on Track with CMS-0057-F Requirements and Compliance
Are You Prepared for the January 1, 2027 Deadline?
The clock is ticking for healthcare payers to meet the stringent requirements of the CMS Interoperability and Prior Authorization Rule, and specifically, the new requirements around CMS-0057-F.
This federal mandate is reshaping prior authorization processes, interoperability, and data transparency - setting a bold standard for how payers, providers, and patients share and access healthcare data. Organizations that fail to comply risk penalties and operational bottlenecks, making it critical to act now.
CMS-0057-F introduces groundbreaking updates focused on improving efficiency and transparency, including:
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New Prior Authorization Deadlines: Standard requests must be processed within seven calendar days, while expedited requests must be completed in 72 hours - regardless of submission method.
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Public Reporting Requirements: Starting in 2026, payers must publicly disclose prior authorization metrics, such as approval rates and average decision times, to enhance accountability.
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Game-Changing APIs: Payers must implement three advanced FHIR-based APIs - Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS) - to streamline prior authorizations for patients and providers.
Vital Data Technology helps you meet key provisions for CMS-0057-F
Tailored specifically to meet the needs of payers, Vital Data Technology's Intelligent Prior Authorization (IPA), part of our end-to-end Affinitē Utilization Management (UM) solution, leverages advanced automation to streamline workflows, verify benefits, and handle time-consuming administrative tasks.
With the help of our CareFlow™ Rules Engine, Affinitē IPA empowers health plans to design customized authorization rules that align with their individual business requirements and regulatory obligations.
And by ensuring compliance with CMS-0057-F, Affinitē UM ensures payers deliver enhanced patient care while significantly reducing administrative costs.
Download the full timeline for a detailed action plan to so you don't miss any important deadlines on the path to implementation!
Timeline: How Health Plans Can Meet CMS-0057-F Compliance by Jan. 1, 2027
Affinitē UM supports CMS-0057-F requirements, including:
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Advanced analytics and reporting capabilities, including real-time and self-service reporting options.
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Prior authorization metrics and provider notice, including denial reasons.
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Support for Medicare Advantage, Medicaid, and Exchange timeliness measures.
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Advanced data integration and transformation capabilities, including real-time data feeds.
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Integration with Availity and existing member portals via single sign-on (SSO).
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Synchronization of benefit coverage and API population with lists of covered items and services requiring prior authorization.
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Customization of coverage requirements based on specific patient and provider details.
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Patient Identity Management or Enterprise Master Patient Index (EMPI) capabilities.
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Support for HL7 FHIR® Da Vinci Coverage Requirements Discovery Implementation Guide, STU 2.0.1.
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Experience with HL7 FHIR standards, including Patient Access API, Payer-to-Payer API, and Provider Directory API.
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Conformance with HL7 Clinical Quality Language (CQL) version 1.5.2.
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Support for Provider Directory API FHIR API system requirements.
Blog
Navigating the 2027 Interoperability and Prior Authorization Rule: Strategies to Consider for Healthcare Payers
The introduction of the 2027 Interoperability and Prior Authorization Rule (CMS-0057-F) by the Centers for Medicare & Medicaid Services (CMS) heralds a pivotal shift in how healthcare payers must operate across the U.S.
This transformative policy is set to redefine data sharing and streamline prior authorization processes, with a clear mandate to enhance patient care and alleviate administrative burdens.
For healthcare payers, this rule presents both a significant challenge and a sizable opportunity to innovate and optimize their operational frameworks.
WHY ACT NOW?
CMS-0057-F compliance requires strategic planning and decisive action. Whether your organization is just beginning the discovery process or has already taken steps forward, there’s still work to be done to ensure success. With the 2027 deadline nearing, now is the time to solidify your approach and address key challenges.
Our tailored solutions are here to meet you where you are. From kickstarting your compliance efforts to refining and advancing your strategy, we provide the tools and expertise to streamline workflows, achieve seamless interoperability, and prepare your organization for full compliance.