By Chris Kenyon, Director of Clinical Solutions, Availity
LinkedIn: Chris Kenyon
LinkedIn: Availity
The Centers for Medicare & Medicaid Services Interoperability and Prior Authorization Final Rule (CMS 0057 F) is often discussed as a health plan problem to solve. Are plans compliant? Are the APIs live? Is the data finally reliable? Those are fair questions, but they’re not the only questions providers should be asking.
Interoperability doesn’t improve simply because one side is required to comply. For providers, CMS 0057 F represents a meaningful opportunity to reduce abrasion in prior authorization, patient intake, and day-to-day workflow but only if providers are prepared to engage, adapt, and act on better information when it becomes available.
So what does the CMS-0057-F make possible for providers and why realizing the value requires more than waiting for payer compliance?
CMS 0057 F and the Provider’s Role in Making It Work
Before we dive in, it’s worth exploring what CMS-0057-F requires and its broader implications. While the rule applies to Medicare Advantage, Medicaid, Children’s Health Insurance Program (CHIP) and Qualified Health Plans on the Federally-Facilitated Exchange, its impact often extends further. In fact, most payers I have spoken to about CMS-0057-F connectivity support realize the value of these requirements and are applying the rule across all lines of their business.
What do CMS-0057-F-impacted payers have to do? Functionally, there are three interdependent “layers” to the requirements: Data, access, and workflow. We’ll walk through them in what may seem like an odd order, starting with the third layer:
- Workflow, which includes the prior authorization suite of APIs (CRD, DTR, PAS). Together, these APIs require plans to create an automated capability to respond to prior authorization policy questions and provide on-demand status updates during review. In addition, the rule stipulates turnaround times for payers. Collectively, the Workflow layer is about transparency into complex policies and processes from payers for providers.
- Data requires affected payers to organize all relevant member data, up to and including clinical data such as lab results and medication history for the past five years, into a central data store built to facilitate exchange (i.e., FHIR). This work started with the Patient Access rule, CMS-9115-F, but has been expanded under CMS-0057-F to include the codification of prior authorization data and policies.
- Access encompasses the Payer-to-Payer and Provider Access APIs and requires that the aforementioned data be made available upon request. If the plan doesn’t have five years’ worth of data on a member, and the member consents, CMS-0057 requires health plans to share historical data with each other. The goal is that when a provider caring for that member makes a request to the health plan to access a patient’s medical history, the provider will receive a relevant clinical history, not simply the administrative artifacts of a member’s utilization patterns.
In theory, these requirements should make it easier for providers to know what’s required per policy guidelines and get answers faster. Past mandates promised better access and transparency, yet the data often didn’t hold up and was so unreliable or inconsistent that it couldn’t be embedded or meaningfully change workflows. That history gives providers every right to be cautious about building processes around requirements that may not deliver as promised.
Providers are at a familiar crossroads. If payer data still isn’t reliable, accurate, or usable enough to support real workflows, waiting is the right call. But CMS 0057 F introduces the possibility that this time could be different. And if it is, providers who hold back entirely risk missing the chance to shape how that information is used.
To ensure value is realized both payers and providers have to be willing to take the leap and work together. The key starting point for providers is to assume you can and will use this additional data in workflows and for operations. Then determine how to test that assumption with a limited scope, a more robust surveillance and measurement of the operational impact, or a combination of the two.
To get prepared and feel confident in developing that testing approach, providers should start by asking payers thoughtful questions about what’s changing and how it will be applied.
Smarter Engagement with Health Plans: Better Questions, Better Outcomes
Once providers decide to engage, the real difference comes down to how they engage with health plans. Too often, provider conversations with payers stop at surface level questions:
- Are you compliant yet?
- Are the APIs live?
Those questions matter, but they don’t determine whether interoperability actually improves day to day work. More meaningful progress comes from shifting the conversation toward operational details that affect real workflows, such as:
- How will policy logic be represented and kept up to date as requirements change?
- How should providers adjust submission behavior to get clearer, faster responses?
- What assumptions are built into automated decisions, and where is human review still expected?
- What clinical context and status updates will be returned to providers, and where will they surface in our workflow?
- How should we work with our health plan counterparts to address API performance issues or data exchange failures?
- How might we help payers collect member consent so that historical data from previous health plans may be collected and shared?
- How will we hold our internal teams accountable to use newly-available data and opportunities for transparency?
By asking these questions early on, providers will be able to influence how these APIs will work with real world workflows. This can help make the data more usable and will align it with how care is actually delivered.
The Risk of Sitting This Out
CMS 0057 F creates a meaningful opening, but it doesn’t deliver value automatically. It asks both sides to show up differently. For providers, that doesn’t mean blind trust or immediate transformation. It means recognizing this moment as an opportunity to engage while expectations are still being defined. As well as an opportunity to ask better questions, influence how information is represented, and help shape what “usable” data actually looks like.
A few potential starting questions for internal provider teams include:
- How can providers support plan efforts to capture Payer-to-Payer consent so historical patient data can be shared with other providers to encourage better coordination of care and understanding of patient history?
- How can our provider organization scope a pilot to understand the value and/or risks of incorporating Provider Access data into our pre-visit workflows?
- Should we create a CMS-0057-F steering committee to define, manage, and track our organization’s adoption of data flow?
This rule is a shared responsibility. Provider organizations that approach CMS–0057-F as something that just “happens to them” will likely find themselves responding to choices made by others. Organizations that approach this as an opportunity to collaborate will be best positioned to see real returns in the form of reduced friction, predictable workflows, and improved patient experience.
By being an active participant in the deployment of CMS-0057-F requirements, provider organizations will be able to help craft the future of their workflows and improve experience for all stakeholders. But only if these organizations are proactively involved.