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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: 

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?

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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.

Health Applications You Can Trust

Prior Auth Savings Calculator
How AI-Augmentation Works

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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: 

Ask the vendor to prove their data quality abilities at scale

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.
Understand how the vendor platform enables use cases beyond mandates

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?
Understand how the vendor is using AI

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?

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Our recommendation is to view the compliance investmentas a way to mature along your strategic roadmap, well beyond the regulatory requirements of the Final Rule.

Video #3: How Da Vinci IGs Improve Implementation Efficiency

In this video, you’ll learn:

✓ The massive benefits of implementing IGs, even though they are only recommended by CMS.

✓ How to improve payer-provider relationships with burden-less PA workflows.

✓ How a FHIR-first and CQL platform is able to meet the requirements of the June 2025 US Payer Pledge for Prior Auth.

Health Applications You Can Trust

FHIR Essential Program
Real-time Prior Auth Use-case

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Steps for Payers to Improve Efficiency with Compliance Implementations

Step One: Get Familiar with FHIR and the Da Vinci IGs

● Allocate time for technical, business, and clinical teams to review the relevant Da Vinci IGs.

● Ensure teams understand the business problem each IG solves, along with the workflows it enables.

● Provide training on FHIR fundamentals if teams aren’t already proficient.
Step Two: Conduct a Thorough Internal Assessment

● Map your current prior authorization process end-to-end, including all provider touch-points, manual step and downstream systems involved.

● Review your current technology stack.

● Assess your privacy and security protocols in light of external-facing APIs and new data exchange requirements.
Step Three: Create a Detailed, Work-back Project Plan

● Use the January 1, 2027 CMS deadline as your work-back date

● Align internal milestones, testing, and change management efforts to the timeline.
Step Four: Engage with Vendor-Partners

● View your vendors as partners. Share assessment findings and collaborate on how their solutions can help you meet compliance requirements.

● Assess vendor capabilities with detailed, specific questions:

● Is the vendor FHIR-first (FHIR-native), or do they rely on transformation layers?
● Which versions of CRD, DTR, and PAS IGs does the vendor support today?
● What is the vendor’s roadmap for adopting new versions or new IGs?
● Can the vendor demo a working implementation of FHIR and Da Vinci IGs?
● What professional services does the vendor offer for IG implementation and integration?

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Our recommendation is to choose a FHIR-first vendor so that the technology you invest in today, is tomorrow-ready.

Video #4: The Compliance Roadmap Beyond Prior Auth

In this video, you’ll learn:

✓ How and why progressive Payers are codifying payer and medical policies

✓ What type of data engine can meet the CMS mandates, and the Payer Pledge for Prior Auth

✓ Why Payers don’t have worry about solving individual use-cases (like PA and quality measures) anymore 

Health Applications You Can Trust

Fixing Systemic PA Denials
Toward Digital HEDIS Measures

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How Smile is Leading the Way

#1 Expertise: Leading the Way

● Smile maintains the HL7 FHIR standard and our platform is the world’s most proven implementation.

● Smile is actively shaping industry standards by leading 31+ HL7 FHIR Working Groups.

● Smile’s CQL engine has been live in production for over 8 years, well before most vendors began investing in CQL for FHIR-based HEDIS measures.

● Key player in NCQA’s DQIC—Digital Quality Implementers Community—a key initiative validating vendor solutions against digital HEDIS measures.
#2 Solution: Powered by FHIR and CQL

● Fully compliant with CMS Prior Authorization (0057-F) requirements.

● Proven real-time prior authorization adjudication using codified medical policy, FHIR and CQL.

● Meets transparency expectations outlined in the Prior Authorization Payer Pledge.

● First and only vendor validated by NCQA under their new digital measure validation framework.

● Enterprise-scale processing, benchmarked at 5 billion data points (for 5 million members) in under 12.5 hours.

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Our recommendation: don’t worry.
Contact Smile for your unique compliance and clinical intelligence implementations. 

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