Interoperability &
Prior Authorization
Every Medicare Advantage, Medicaid, CHIP, and QHP issuer must implement FHIR APIs and transform prior authorization processes by January 1, 2027.
Critical compliance dates
Operational Requirements Begin
Prior authorization decision timeframes take effect: 72 hours for urgent, 7 days for standard. All denials must include specific reasons.
First Public Metrics Due
Initial prior authorization metrics must be publicly posted. Annual reporting required thereafter for transparency.
Full API Implementation
All five FHIR APIs must be live. MIPS eligible clinicians begin electronic prior authorization attestation.
Five APIs that transform healthcare data exchange
Patient Access API
Extend existing Patient Access APIs to include prior authorization decisions, giving patients complete visibility into authorization status and care impact.
- Prior authorization decisions (excluding drugs)
- Claims and encounter data
- USCDI data elements
- Annual usage metrics reporting to CMS
Provider Access API
Enable in-network providers to access patient data for care coordination and support value-based payment models.
- Claims and encounter data
- USCDI data classes and elements
- Prior authorization information
- Patient attribution process
Payer-to-Payer API
Support care continuity when patients change plans by enabling seamless data exchange between payers.
- 5 years of claims and encounter data
- USCDI data elements
- Prior authorization records
- Patient opt-in process
Prior authorization transformed
Built on industry standards
Who must comply
Medicare Advantage (MA) Organizations
State Medicaid & CHIP Fee-for-Service Programs
Medicaid Managed Care Plans
CHIP Managed Care Entities
Qualified Health Plan (QHP) Issuers on Federally Facilitated Exchanges
Ready to ensure compliance?
Get our comprehensive RFP template designed to help you navigate CMS-0057-F requirements and achieve regulatory success.
Download RFP TemplateComprehensive RFP template for CMS-0057-F compliance
API Development & FHIR Implementation
Complete technical architecture for all five required APIs using HL7 FHIR 4.0.1, implementation guides, and compliance with all CMS specifications.
Data Integration & USCDI Compliance
Comprehensive data mapping strategy ensuring all required USCDI data elements are properly exposed with appropriate consent and privacy controls.
Security & Authentication
Implementation of SMART App Launch Framework, OpenID Connect, OAuth 2.0, and FHIR Bulk Data Access with enterprise-grade security controls.
Prior Authorization Workflow Automation
Electronic prior authorization system supporting request submission, decision processing within regulatory timeframes, and denial documentation.
Metrics Collection & Public Reporting
Automated systems for tracking and publicly reporting prior authorization metrics and Patient Access API usage on required timelines.
Provider Attribution & Patient Consent
Attribution processes associating patients with providers, opt-in/opt-out mechanisms, and plain-language educational materials.
Testing, Documentation & Training
Comprehensive testing strategy including integration, security, and performance testing with complete documentation and staff training programs.
Timeline & Phased Implementation
Detailed project timeline meeting both January 1, 2026 and January 1, 2027 compliance deadlines with phased rollout and contingency planning.