With the enforcement date of CMS-0057-F—January 1st 2027—fast approaching, a lot of Payers are attempting to modernize their Prior Auth workflow requirements. The requirements of the mandates have a large technical aspect, however, there are operational and strategic considerations as well as managing relationships with Providers.
This 4-part video series offers payers essential context and actionable steps to make smarter CMS compliance investments—both in the short and long term—while reducing burdens, streamlining operations and providing better provider/member experiences. Each video explores a key area of focus, including:
Video #1: Evolving Tech Stack for PriorAuth and Beyond
In this video, you’ll learn.
✓ How Payers can navigate the evolution of Prior Authorization (PA) modernization, especially under CMS-0057-F.
✓ How to manage operations and technical evolution of legacy standards—like X12—while adapting to new technologies like FHIR®.
✓ What to expect as PriorAuth shifts from manual to automated workflows, and what that means for Provider relationships.
✓ How to balance near-term requirements with long-term strategy.
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Selecting a Vendor-Partner
Selecting a CMS interoperability vendor isn’t just about getting compliant. It’s about future-proofing your organization, empowering better member experiences, and driving real ROI from your data strategy. When choosing a vendor-partner, make sure to:
Look for:
- A vision that extends beyond regulatory compliance.
- Technical evidence that they’re not just standing up APIs to ‘check-the-box’, and have demonstrable solutions that improve and streamline workflows.
- Plans (and technology) to evolve into new use cases, such as risk adjustment, and care-gap closure that would enhance member and provider satisfaction.
Don’t just ask if they “support FHIR.” Dig deeper:
- Are they based on a FHIR-native architecture?
- Do they actively participate in HL7 Technical Working Groups or help shape industry guidance?
- Do they have experience and expertise with Da Vinci Implementation Guides (IGs), and innovating with CQL?
- How do they leverage AI in their tooling? Do they use a deterministic evidence-based approach, or a probability-based approach?
- Do they offer technical and support services for provider education and onboarding support?
- Can they handle workflows like CDA ingestion and clinical data reconciliation?
- Are their systems battle-tested at scale in real-world implementations?
Our recommendation is to look for FHIR-first vendor-partners, who can meet you where you are today, and help you mature along your future roadmap.
Video# 2: True Cost-Saving Potential of Compliance Investments
In this video, you’ll learn.
✓ Why simply meeting the CMS 0057-F mandate with APIs isn't enough to deliver ROI.
✓ How intelligent automation—paired with high-quality data—reduces the true cost of prior authorization.
✓ The potential for tens of millions in savings by reducing the $16 per-transaction PA cost through automation.
✓ How to build a strong financial justification strategy to secure internal funding and leadership buy-in.
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Going Beyond the Mandates—Smart Business Steps for Payers
Standing up the APIs associated with CMS-0057-F isn’t enough. Progressive Payers are modernizing their infrastructure to reduce administrative costs and burdens, and create a base of quality data upon which intelligent automations can run. When choosing a compliance vendor-partner, make sure to:
Look for:
- A data strategy that goes beyond API enablement and into data normalization, enrichment, and deduplication—essential for powering downstream use cases.
- Tools and automation that detect and correct data issues in real-time.
- An architecture that supports comprehensive, longitudinal records and analytics-ready data.
Can the vendor help you activate your data for:
- Risk adjustment and quality programs?
- Real-time prior authorization and care coordination?
- Utilization management or member engagement initiatives?
Is the vendor:
- Leveraging clinical guidelines and industry best practices?
- Able to prove consistent and accurate PA adjudications?
- Able to use an AI approach that resolves systemic biases, and is transparent and auditable?
Our recommendation is to view the compliance investment as a way to mature along your strategic roadmap, well beyond the regulatory requirements of the Final Rule.