The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is a sweeping federal regulation with major implications for managed care organizations (MCOs). With the first deadlines approaching in 2026, this rule introduces both technical and operational changes that are intended to improve the speed, transparency, and coordination of prior authorization processes.
Take a closer look at what CMS‑0057‑F includes, what it requires from MCOs, and how organizations can begin planning for compliance.
What Is CMS‑0057‑F?
Issued by the Centers for Medicare & Medicaid Services (CMS) on January 17, 2024, the Interoperability and Prior Authorization Final Rule is designed to tackle long-standing frustrations with manual prior authorization workflows.1 It focuses on two major priorities: improving the flow of healthcare data across payers, providers, and members; and replacing paper- or fax-based processes with fast, digital alternatives.
CMS‑0057‑F stems from the May 2020 CMS Interoperability and Patient Access final rule (85 FR 25510) and mandates that payers must implement Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) and application programming interfaces (APIs).2
This interoperability rule applies to:
- Medicare Advantage organizations
- Medicaid managed care and fee-for-service (FFS)
- CHIP managed care and FFS
- Qualified Health Plans (QHPs) on the Federally Facilitated Exchanges
What Will CMS‑0057‑F Require?
CMS‑0057‑F and FHIR® prior authorization introduces new technology expectations and faster timelines for decision-making, among other provisions. Key requirements include:2
- Prior Authorization API: Maintain a Prior Authorization API that lists covered services, outlines documentation requirements, processes requests and responses, and clearly communicates approvals, denials with reasons, or requests for more information.
- Patient Access API: Add information about prior authorizations to the data available in a Patient Access API to offer patients greater data access and help them understand the impact of prior authorization on their care.
- Provider Access API: Maintain a Provider Access API that enables data sharing with in-network providers, including claims, USCDI data, and select prior authorization details, to support care coordination and value-based payment models.
- Payer-to-Payer API: Maintain a Payer-to-Payer API that allows the exchange of claims, encounter records, USCDI data, and select prior authorization details (excluding drug-related information) with other payers.
Compliance Timeline
The first major compliance milestone for the Interoperability and Prior Authorization Final Rule is January 1, 2026, when impacted payers must begin accepting electronic prior authorization requests and responding within the required timeframes (72 hours for expedited requests and 7 calendar days for standard ones).1
One year later, by January 1, 2027, payers are expected to have fully implemented the required APIs, including the Prior Authorization, Provider Access, Patient Access, and Payer-to-Payer APIs. Public reporting of prior authorization metrics also begins at this stage, marking full compliance with the rule’s interoperability and transparency objectives.1
What Should MCOs Be Thinking About Now?
Many organizations started planning for CMS‑0057‑F over a year ago, so it’s time to speed up preparation. A thoughtful, phased approach can help reduce risk and avoid last-minute scrambles as deadlines near. Here are a few areas worth focusing on:
1. Assess Where You Stand
Start with a high-level gap analysis to understand how your current operations compare with CMS‑0057‑F requirements. This will help identify where updates are needed, whether in technology, workflows, or communications, and then lay the groundwork for a successful implementation.
- Do you currently support FHIR-based APIs?
- Are your turnaround times within 72 hours (expedited) and 7 days (standard)?
- Do you have an easily accessible, up-to-date prior authorization list electronically available to providers?
- Do you provide standardized, specific denial reasons?
- Can you exchange data across care transitions with other payers?
- How do you handle provider and patient access to authorization data?
- Are your claims and prior auth records ready for public reporting?
2. Set the Right Structure
Successfully implementing CMS‑0057‑F will require strong governance and internal coordination. Create a cross-functional task force that includes representatives from IT, clinical operations, compliance, provider relations, and legal. Have this group get together regularly to review progress, troubleshoot issues, and stay aligned.
Equally important is executive sponsorship; senior leadership must prioritize this initiative to secure the necessary budget, resources, and long-term support. Without clear governance, even well-planned technical solutions can stall when cross-team collaboration is lacking.
3. Evaluate Technology Needs
Technology will provide the framework for compliance, not just with this interoperability rule but with everything in the future of the healthcare industry. Now is the time to inventory your current systems and assess their readiness to support the four required FHIR APIs. Consider whether to build in-house or work with external vendors who specialize in API enablement, automation, or interoperability middleware.
You’ll also want to evaluate your prior authorization platform’s ability to support automated submissions, real-time tracking, and structured responses. Investing in scalable, secure solutions now can reduce rework later and help future-proof your operations as the industry moves further toward value-based care and real-time data exchange.
4. Plan for Provider Engagement
Even with the best technology in place, the transition to electronic prior authorization and interoperability in healthcare will only go smoothly if your provider network is on board. Many providers are still adjusting to digital submission workflows and may need education, training, and support to comply with new expectations.
Proactive outreach can go a long way toward reducing friction and improving turnaround times. Think about segmenting your provider communications based on size, readiness, or past engagement with prior auth processes, so that your messaging and support resources are appropriately tailored.
Consider offering providers:
- Updated documentation on new submission workflows
- Live or recorded onboarding sessions for key provider groups
- One-on-one support for high-volume or high-priority practices
- FAQs and tip sheets for quick reference during implementation
- A designated support contact for authorization-related questions
- Regular progress updates and reminders tied to CMS deadlines
More Than a Compliance Checklist
While CMS‑0057‑F may initially seem like another administrative mandate, it stands as a meaningful opportunity for managed care organizations to modernize and improve how they operate. By automating repetitive processes, strengthening interoperability, and improving transparency, organizations have new opportunities to build stronger relationships with providers and patients alike.
Still intimidated and unsure of where to start in your team’s prep?
Clearlink helps MCOs stay ahead of regulatory change while pursuing operational excellence. From interoperability in healthcare planning to managed services, our team is ready to support your organization as it prepares for what’s next.
Contact us for more information on CMS‑0057‑F planning and our full range of capabilities for payers. We’ll help you translate federal requirements into clear priorities, tailored strategies, and tangible progress and ultimately feel comfortable tackling the challenges of interoperability in healthcare.
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