January 1, 2027, is the effective date of the API component of the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), so the compliance deadline is coming up fast.
Let’s dig into what interoperability means in terms of this rule, who needs to meet these requirements, and what you need to do now.
CMS published the final rule on January 17, 2024, and implementation has been divided into two stages. The operational stage commenced in 2026, while the technical API stage will roll out in 2027. CMS expects that these policies will help reduce administrative costs by $15 billion over 10 years.
CMS-0057-F Key Dates
|
Date |
What applies |
|
Jan. 1, 2026 |
Decisions within 72 hours (urgent) or 7 calendar days (standard), and payers must give specific denial reasons; public reporting of prior authorization metrics begins |
|
March 31, 2026 |
First prior authorization metrics report due |
|
Jan. 1, 2027 |
Patient Access, Provider Access, Payer-to-Payer and Prior Authorization APIs must be live |
|
Performance year 2027 |
New electronic prior authorization measure for hospitals, including designated Critical Access Hospitals |
The requirement is applicable to "affected payers," namely, Medicare Advantage organizations, state Medicaid/CHIP fee-for-service programs, Medicaid managed care programs, CHIP managed care programs, and issuers of qualified health plans on federally facilitated insurance exchanges. It does not apply to traditional fee-for-service Medicare, commercial health plans, plans issued on state-based exchanges, and prescription drug coverage.
Payers need to provide information about any claims with a date of service five years before the request.
|
API |
What it does |
Patient consent |
|
Patient Access |
Lets patients view claims, clinical data and prior authorization status through third-party apps |
Patient-directed |
|
Provider Access |
Lets in-network providers pull claims, encounter and clinical data, singly or in bulk |
Opt-out |
|
Payer-to-Payer |
Lets a new payer retrieve data from a former or concurrent payer, limited to the past five years |
Opt-in |
|
Prior Authorization |
Lets providers check requirements, learn documentation needs, and submit requests |
Not applicable |
The Provider Access and Payer-to-Payer APIs move large volumes of records, so CMS expects payers to use FHIR Bulk Data Access (also known as Flat FHIR) exports.
The API can only pass on information available within the source system, so data quality matters. Duplicate in patient identification numbers, missing encounters, and conflicting information appear as data gaps when requested by a provider or payer. Hart builds healthcare data integration solutions that normalize and validate records from multiple EHRs using FHIR, HL7 and C-CDA, without asking organizations to replace their existing systems.
In the cases including Medicaid managed care, the former standard had a deadline of 14 days for nonurgent cases. Now the cap is only 7 days. Those who use faxes and telephone communications will start to feel the pinch first.
Prior-authorization requests will require clinical history, and so much historical data is locked up in obsolete EHRs. Proper healthcare data archiving offers access from searchable repositories. Our legacy EHR data archival guide explains the approach in more detail.
For a deeper look at the integration side, see Benefits of Professional Healthcare Data Integration Services for hospitals.