Understanding CMS Rule 0057 Requirements
The Centers for Medicare and Medicaid Services (CMS) Rule 0057 mandates that health plans develop and implement FHIR-based APIs to streamline electronic prior authorization (ePA). This significant regulatory change aims to reduce administrative burden, improve response times, and enhance overall healthcare delivery. However, the ultimate return on investment extends beyond mere compliance. With strategic implementation, health plans can transform this requirement into an opportunity for improved member satisfaction, enhanced provider relationships, and substantial operational efficiency.
Based on extensive collaboration with early adopters, InterSystems has identified five critical questions health plans must address to maximize their ePA implementation success. These insights provide a roadmap for organizations seeking to move beyond basic compliance toward meaningful transformation.
Connecting Back-Office Systems to FHIR APIs
What’s needed to connect my plan’s back-office coverage and utilization management systems to the required FHIR APIs?
Successful implementation requires two essential technological components: a smart API broker and a robust data integration engine. Health plans typically must query multiple disparate systems to determine prior authorization requirements, including member eligibility databases, policy coverage platforms, and provider status verification systems.
Additionally, most plans utilize a complex ecosystem of proprietary medical policies, licensed rules engines, and delegated vendor relationships to evaluate and adjudicate authorization submissions. This complexity necessitates an API broker capable of automatically routing specific requests to the appropriate back-office system based on the request type and parameters.
Furthermore, many legacy systems do not natively support FHIR standards or may implement inconsistent versions of these standards. A sophisticated data integration engine bridges this gap by enabling bidirectional flow of normalized data that all systems can effectively process, ensuring seamless communication across the technology ecosystem.
Translating Medical Policies for Machine Readability
Are there best practices for translating medical policies governing prior authorization into machine-readable language?
The most effective approach is applying the 80/20 principle to accelerate your return on investment. Converting all medical policies related to prior authorization into machine-readable formats represents an extensive, ongoing undertaking for most health plans. However, organizations can prioritize strategically by identifying which procedures generate the highest volume of authorization requests.
Health plans partnering with InterSystems consistently report that a relatively small subset of procedures accounts for a disproportionately large share of authorization requests. By identifying this subset and prioritizing the translation of corresponding medical policies into machine-readable language, plans can maximize impact while minimizing initial resource investment.
This targeted approach delivers faster prior authorization decisions for the maximum number of members and providers while reducing the volume of requests requiring costly manual intervention. As systems mature, plans can progressively expand their machine-readable policy library to cover additional procedures.
Driving Provider Adoption of ePA Processes
How can my plan drive provider utilization of the ePA process mandated by CMS Rule 0057?
The key to widespread adoption lies in ensuring your ePA solution delivers a reliable, time-saving experience from day one. While CMS-0057 requires that providers attempt the new FHIR-based process, it doesn’t mandate consistent usage. This makes the initial user experience critically important to driving sustained adoption.
When technological change is optional, negative first impressions can severely limit adoption of new processes, regardless of subsequent improvements or potential benefits. Provider education initiatives about optimal ePA utilization are valuable, but the fundamental driver of adoption will be technology that functions reliably and efficiently from the very first interaction.
Health plans should thoroughly test their ePA implementations with real-world scenarios before launch and consider a phased rollout approach with trusted provider partners to identify and address any potential issues before widespread deployment.
Scaling to All Lines of Business
Can this functionality be readily scaled to all lines of business, including our commercial products?
Yes, scaling is achievable with proper architectural planning that addresses three critical factors:
- Transaction Volume Capacity – Your system must process substantially higher query volumes without compromising reliability or data fidelity as you expand across lines of business.
- Administrative System Integration – Your API broker needs the capability to route queries across what may appear to be redundant systems serving different business lines with potentially different requirements and workflows.
- Varying Prioritization Needs – Different lines of business may require different subsets of medical policies to be prioritized for machine-readable translation based on their unique authorization patterns and member needs.
By proactively addressing these considerations in your implementation strategy, you can create a scalable foundation that supports expansion across your entire organization while maintaining performance and reliability.
Leveraging AI for Prior Authorization Improvement
Can AI help reduce frustration with prior authorization?
Absolutely. InterSystems is actively developing AI applications designed to streamline complex authorization processes and diagnose systemic bottlenecks. These solutions offer significant potential for reducing administrative burden and improving outcomes.
However, the effectiveness of all healthcare AI applications depends on a fundamental prerequisite: high-quality data. AI solutions require substantial volumes of timely, accurate information to meaningfully improve prior authorization processes and support broader value-based care initiatives.
To harness AI’s transformative potential, health plan leaders must pair their AI implementation strategies with investments in comprehensive data infrastructure. This includes developing harmonized, normalized data repositories that effectively integrate diverse clinical, administrative, and social determinants of health (SDOH) information streams. These integrated data assets must be readily accessible for multiple use cases to maximize their organizational value.
Moving Forward with Electronic Prior Authorization
The implementation of CMS Rule 0057 represents both a compliance requirement and a strategic opportunity. By addressing these five critical questions, health plans can position themselves to deliver improved experiences for members and providers while achieving meaningful operational efficiencies.
Organizations that approach electronic prior authorization with thoughtful planning, targeted implementation strategies, and a focus on user experience will be best positioned to transform this regulatory requirement into a competitive advantage. As healthcare continues its digital transformation, those who excel at streamlining administrative processes like prior authorization will contribute significantly to improving the overall healthcare experience.
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