Healthcare organizations across the United States are racing against time to meet the stringent requirements of the Centers for Medicare and Medicaid Services Interoperability and Prior Authorization Final Rule (CMS-0057), which takes full effect in January 2027. According to industry experts, most providers and payers remain unprepared for the sweeping changes that will fundamentally reshape how healthcare data is exchanged and prior authorizations are processed.
Understanding the CMS-0057 Final Rule
Released in January 2024, the CMS Interoperability and Prior Authorization Final Rule represents a landmark regulatory shift in healthcare data exchange and administrative processes. The rule specifically targets how healthcare organizations, particularly payers, must handle prior authorizations and implement standardized data exchange protocols to improve care coordination and reduce administrative burden.
Scott Rossignol, consultant for FHIR Solutions at eHealth Exchange, emphasized during preparations for the 2026 HIMSS Global Health Conference & Exhibition in Las Vegas that healthcare organizations are significantly behind schedule in their compliance efforts. His session, titled “CMS 0057 and ePrior Authorization: What Providers and Payers Need to Know,” forms part of the Interoperability & HIE Preconference Forum at HIMSS26 and aims to provide critical guidance for organizations struggling to meet these requirements.
Which Healthcare Organizations Are Impacted?
The final rule’s mandates affect a broad spectrum of healthcare payers, including:
- Medicare Advantage plans
- Medicaid managed care organizations
- Children’s Health Insurance Program (CHIP) plans
- Affordable Care Act (ACA) exchange plans
These organizations must implement comprehensive application programming interface (API) infrastructure to facilitate seamless data exchange between payers, providers, and patients. The rule requires full implementation of three critical APIs: the Prior Authorization API, Provider Access API, and an expanded Patient Access API.
Key Technical Requirements and Implementation Challenges
API Integration Mandates
Payers must develop and deploy APIs that enable healthcare providers to submit prior authorization requests and receive electronic decisions directly within their electronic health record (EHR) or practice management systems. This integration eliminates the need for providers to navigate separate payer portals or submit paper-based authorization requests, significantly streamlining workflows.
Accelerated Decision Timelines
Beginning in 2026, payers faced initial requirements for faster prior authorization decision-making. However, the 2027 mandates extend far beyond these preliminary requirements, introducing technical and operational challenges that many organizations find daunting to implement within the compliance timeline.
The HL7 Da Vinci Project Connection
Rossignol’s session will focus extensively on practical implementation experiences rather than theoretical regulatory interpretation. The presentation will showcase real-world pilot projects conducted within the HL7 Da Vinci Project framework, a private-sector initiative designed to accelerate adoption of HL7 FHIR (Fast Healthcare Interoperability Resources) standards.
The Da Vinci Project serves as a collaborative testing ground where payers and providers can experiment with FHIR-based data exchange technologies before full-scale production deployment. “We create pilots to stand up the technologies,” Rossignol explained. “You can be successful and save money” through these iterative implementation approaches.
Practical Implementation Strategies
The HIMSS26 session will address critical operational questions that healthcare organizations face:
- How providers will transmit clinical and administrative data to payers using standardized FHIR APIs
- How payers will respond to provider data submissions and communicate authorization decisions electronically
- Best practices derived from successful pilot implementations in the Da Vinci collaborative
- Cost-effective strategies for meeting compliance requirements without overextending IT budgets
Expert Panel Insights
Rossignol will be joined by three distinguished healthcare informatics leaders who bring diverse organizational perspectives to the implementation challenge:
- Srihari Muthyala, Director of Health Care Solutions and Interoperability at Cambia Health Solutions
- Anna Taylor, Assistant Vice President of Population Health & Value Based Care for MultiCare Health System
- Michael Westover, Vice President of Pop Health Informatics at Providence
This panel composition ensures representation from both payer and provider perspectives, offering attendees comprehensive insights into bilateral implementation challenges and solutions.
Timeline for Compliance
Healthcare organizations must prioritize their interoperability infrastructure development immediately to meet the January 2027 deadline. The session at HIMSS26, scheduled for Monday, March 9, at 10:35 a.m. in Las Vegas, provides a critical opportunity for organizations to gain actionable intelligence and accelerate their compliance readiness.
The stakes are high: non-compliance could result in regulatory penalties and operational disruptions that compromise patient care coordination. Organizations that proactively engage with FHIR standards implementation through collaborative initiatives like the Da Vinci Project position themselves for successful, cost-effective compliance while simultaneously improving their overall data exchange capabilities and care coordination efficiency.
