If your organization hasn’t yet started planning for CMS-0057-F, now’s the time to rethink your strategy. While this regulation introduces new ways to streamline prior authorizations and improve data sharing, it also comes with serious implications for those who delay action.
In this post, we’ll explore what could go wrong if you ignore the rule—or assume you can tackle it last-minute.
1. Delayed Prior Authorizations Will Become a Liability
Under CMS-0057-F, payers are required to meet strict timelines:
- Standard requests: 7 calendar days
- Expedited requests: 72 hours
Failing to meet these deadlines—especially without a compliant tracking and response system—could lead to increased provider abrasion, patient dissatisfaction, and scrutiny from CMS. Even worse, non-compliance could result in penalties, enforcement action, or reputational harm in the marketplace.
What happens if you’re not ready?
You may find yourself scrambling to justify delays, while your competitors gain favor with providers and patients by being faster and more transparent.
2. Your Metrics Will Be on Display—Whether You’re Proud of Them or Not
Starting in 2026, CMS will require payers to publicly report key prior authorization performance metrics, including:
- Approval and denial rates
- Average decision turnaround time
- Appeals data
If you’re not already tracking this information accurately—or if your numbers are unfavorable—CMS-0057-F will expose these gaps. Worse, your organization could end up at the bottom of performance comparison lists used by providers and members when choosing plans.
What happens if you’re not ready?
You’ll be forced to scramble to pull together and clean up data that should have been collected over months or years—possibly resulting in inaccurate reporting or compliance violations.
3. You’ll Miss the Efficiency Gains the APIs Were Designed to Deliver
Three new prior authorization FHIR APIs are central to this rule and must be implemented by January 1, 2027. If you wait too long to evaluate vendors, modernize workflows, or involve IT and compliance teams, your organization will face:
- High costs from rushed implementation
- Increased strain on internal teams
- Risk of delivering APIs that don’t meet CMS requirements
What happens if you’re not ready?
You’ll fall behind competitors who already use these APIs to offer faster decisions, automate documentation, and reduce administrative burden.
4. You’ll Fail to Meet Expectations Around Data Transparency
Similar to the prior authorization APIs, the Provider Access and Payer-to-Payer APIs also have looming deadlines. These APIs are designed to:
- Give in-network providers access to patients’ claims and encounter data
- Allow payers to share five years of claims data when a member switches plans
What happens if you’re not ready?
Your plan may be seen as less interoperable and less provider-friendly—two things that are becoming table stakes in today’s healthcare landscape.
5. You’ll Be Playing Catch-Up While Others Are Moving Ahead
By 2026, your APIs must be fully implemented and data ready to submit. If you wait too long to act, your organization risks:
- Non-compliance fines or CMS action
- Friction with providers who now expect near-instant data access
- Losing out on value-based care partnerships that require seamless data sharing
In Summary: Inaction Has a Cost
CMS-0057-F isn’t just another regulation—it’s a roadmap to a more efficient, transparent, and connected healthcare system. But only for those who prepare. The further behind you fall, the harder (and more expensive) it will be to catch up.
Start now. Get your operations in shape, assess your API capabilities, and engage vendors and compliance teams early.
Need help making sense of what this means for your organization? Let’s talk. mPulse is actively supporting health plans through this transformation.
