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From Mandates to Momentum— a Payer Focused Video Series

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: 

How to uncover the true cost-saving potential of CMS compliance
Demystifying Da Vinci IGs—practical guidance on Implementation Guides
How to build a forward-looking compliance roadmap beyond current mandates

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:

✓ Ask vendors to walk you through their product roadmap

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.

✓ Ask about their tenure and depth of expertise?

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?

✓ Confirm Scalability and Provider-Readiness?

- 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. 

 

Stay Tuned for Our Next Video on: Unveiling the Cost-Saving Potential of Compliance Investments