If you’re in healthcare, you’ve probably heard about CMS-0057-F and the changes it brings, especially around prior authorizations. But what does it mean, and how can your organization stay on top of it? In this post, we’ll break down the key measures of CMS-0057-F in simple terms and give you a timeline to ensure you’re ready for what’s coming.
What’s in CMS-0057-F?
Let’s start with the basics. CMS-0057-F is designed to improve the handling of prior authorizations and the sharing of healthcare data while making things more transparent for patients, providers, and payers.
1. New Deadlines for Prior Authorization Decisions
The big change here is that payers now have stricter deadlines to decide on prior authorization requests:
- For standard requests, you’ve got 7 calendar days.
- For expedited requests, it’s 72 hours.
This rule applies regardless of how the request comes in (fax, email, electronic, etc.). You’ll need to provide clear, specific reasons for all denials.
2. Public Reporting on Prior Authorization Metrics
Starting in 2026, payers must post key metrics about their prior authorization processes on their public website. You’ll be reporting things like:
- How many requests do you approve, deny, or approve after an appeal.
- The average time it takes to make a decision.
This info will need to be updated annually, giving patients and CMS insight into how well you’re handling these requests.
3. APIs to Streamline Prior Authorizations
CMS-0057-F introduces three new APIs that aim to make the whole prior authorization process faster and easier:
Coverage Requirements Discovery (CRD) API: This lets providers check if a prior authorization is needed based on the patient’s benefits and provides guidance on next steps.
Documentation Templates and Rules (DTR) API: Helps providers gather and submit the right documentation for the prior authorization.
Prior Authorization Support (PAS) API: This is where the actual prior authorization request happens and where you’ll exchange status updates and final decisions.
4. Payer-to-Payer Data Sharing
The Payer-to-Payer API allows payers to share claims and encounter data when a patient opts-in. If a patient switches insurers, the new payer can request up to five years of historical data from the previous one.
5. Provider Access API
The Provider Access API lets in-network providers access a patient’s claims and encounter data (treatments, medications, encounters, etc.) to help with care decisions. Patients can opt-out of this data sharing.
Your CMS-0057-F Compliance Timeline
So now that you know what CMS-0057-F involves, let’s talk about what you need to do—and when.
2024: Tighten Up Your Prior Authorization Process
The main focus this year is getting your prior authorization process in shape:
- Meet the new decision deadlines: Make sure your system is ready to process standard requests in 7 days and expedited ones in 72 hours.
- Provide clear denial reasons: No matter how the request comes in, make sure you’re giving providers detailed explanations for any denials.
Action Step: Audit your current processes and make any needed adjustments to meet these stricter timelines.
2025: Start Collecting Data and Plan Your API Implementations
In 2025, you’ll be focusing on data collection and prepping for API rollouts:
- Gather prior authorization data: This includes approval/denial rates, reasons for denials, and how long it takes to process requests.
- Track Patient Access API use: Start monitoring how patients use this API (e.g., what data is being accessed, how often, etc.).
- Plan your API implementations: It’s time to start working on the Provider Access, Payer-to-Payer, and Prior Authorization APIs. Get your FHIR API vendor involved and start building educational resources for providers and members.
Action Step: Make sure your systems can collect and store the necessary data, vet and select a vendor to provide the needed FHIR APIs, and begin prepping your team for the API implementations.
2026: Go Live with Your APIs and Publish Your Data
By 2026, everything needs to be up and running:
- Post your prior authorization metrics: This should include measures such as approval/denial rates, average decision times, and appeal outcomes.
- Submit data to CMS: You’ll be required to submit aggregated, de-identified data on Patient Access API use to CMS, though the exact format is still being finalized.
- Prepare to launch your APIs: The Provider Access, Payer-to-Payer, and Prior Authorization APIs should be live by January 1, 2027. You’ll also need a process for patients to opt-out of data sharing and for providers to access the necessary data.
Action Step: Make sure your website is ready to display prior authorization metrics by the end of Q1 2026, submit your Patient Access API data to CMS, and your FHIR APIs will be ready to go live before January 1, 2027.
Get Ready for What’s Ahead
CMS-0057-F is shaking up how prior authorizations are handled and introduces new FHIR APIs. Ultimately these changes will help create operational efficiencies, speed up the delivery of care, and improve experiences for health consumers, providers and payers alike. With the proper preparation and planning, your organization can stay compliant and improve how you manage these processes. By sticking to this timeline and focusing on process improvements, you’ll be well ahead of the game when 2027 rolls around.
The key is starting early—get your IT, compliance, and API teams involved now to ensure smooth operation when it’s time to go live. mPulse continues to partner with our clients to ensure their compliance success, if you would like to connect to discuss more, reach out here to meet with our experts.
