CMS-0057-F API readiness before the January 2027 deadline.
The CMS Interoperability and Prior Authorization rule requires impacted payers to run four FHIR APIs from January 1, 2027. We assess where you stand and build what is missing.
- Deadline
- January 1, 2027 for most impacted payers (dates vary by plan type)
- APIs
- Patient Access, Provider Access, Payer-to-Payer, Prior Authorization
- Guides
- Da Vinci CRD, DTR and PAS; CARIN Blue Button; US Core
- Gap report
- 2 weeks
The challenge
What the rule asks for
CMS-0057-F applies to Medicare Advantage organisations, Medicaid and CHIP programs and managed care plans, and QHP issuers on the federally facilitated exchanges. Since January 2026 most of them must decide prior-auth requests within 72 hours (expedited) or 7 calendar days (standard), give a specific reason for denials and publish prior-auth metrics.
From January 1, 2027 they must also expand the Patient Access API to include prior-auth information and run Provider Access, Payer-to-Payer and Prior Authorization APIs. Exact dates depend on plan type, so confirm yours against the CMS rule.
Sources: CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)
Scope
How we help
- Readiness gap reportAPI by API: what exists, what is missing, which implementation guides apply and a realistic plan to the deadline.
- FHIR API deliveryFHIR R4 APIs on your platform or a FHIR server, mapped from claims, clinical and prior-auth data.
- Prior Authorization APICoverage requirements, documentation templates and submission flows aligned with Da Vinci CRD, DTR and PAS.
- Data mappingX12 278, 837 and 835 data mapped to FHIR resources, with tests against reference implementations.
- Metrics reportingPrior-auth decision timing and outcome metrics calculated from your data and ready to publish.
How it runs
Clear stages. You decide at the end of each.
Assess
Review systems, data and plan types. Deliver the gap report.
2 weeksDesign
Architecture, FHIR server choice, data mappings and test plan.
2 weeksBuild
APIs, mappings, security and conformance testing.
8–12 weeksOperate
Monitoring, onboarding of third-party apps and providers, metrics.
ongoingQuestions
What teams ask us about this.
Is it too late to start before January 2027?
A gap assessment takes two weeks and tells you what can realistically be live by the deadline and what needs a documented plan. Starting now is far better than starting in December.
Can you work with our existing FHIR server or vendor?
Yes. We extend what you have, whether that is a cloud FHIR service, an open-source server or a vendor platform.
Do providers benefit too?
Yes. Provider groups can use the Prior Authorization API to cut phone and fax work, and we build the provider-side integration as well.
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