How Payers Are Advancing on CMS-0057-F | Smile Digital Health

Several large US Payers partnering with Smile Digital Health are already making demonstrable progress toward CMS-0057-F compliance. Our clients are testing and validating automated, FHIR®-native Prior Authorization (PA) processing from initial inquiry to adjudication; aligning with the Da Vinci Implementation Guides for CRD (Coverage Rules Discovery), DTR (Document Templates & Rules), and PAS (Prior Authorization Support). 

During a recent client pilot, we successfully implemented an end-to-end automated PA workflow from CDS Hooks initiation (within a Provider EHR) to Payer submission via FHIR APIs.

By running pilots with live data in real production environments and network architectures, our clients have validated scalable approaches that mitigate risk while confidently expanding Smile CMS and PA solutions across their networks. These implementation pilots have not only demonstrated accurate and transparent PA automation, but have also reduced manual effort, processing time and administrative burden.

Smile Digital Health actively shapes and contributes to the HL7 FHIR and CQL open standards, as well as Da Vinci Implementation Guides.

Meeting the January 1, 2026 Milestone

The next key compliance milestone arrives on January 1, 2026. By then, Payers must:

• Report on Patient Access API usage

• Track and report Prior Authorization metrics

• Provide rationale for denied Prior Auth requests

• Meet turnaround time requirements of 3 days (expedited) or 7 days (standard)

While many Payers are on track to achieving this milestone in collaboration with their PriorAuth delegates and Providers, some organizations remain in the early stages of this effort.

Impact on PriorAuth Delegates and Providers

There is strategic value in ensuring data is received from all Provider EHRs and external delegates, and is included in the CMS strategy.

Prior Authorization Delegates and Providers are starting to realize the intricacies and importance of the CMS specifications. Their Payer networks who are still early in their own CMS alignment efforts, either evaluating vendors, scoping internal capabilities or awaiting further direction from CMS, have already fallen behind on regulatory readiness.

The downstream consequences of delayed action include: CMS penalties for non-adherence, low provider and member satisfaction, and high-touch complex, disjointed solutions that appear to meet the mandates, but end up costing more in technical and operational resources. 

How to Catch Up Before 2025 Year-End 

1. Technical & Operational Gaps
   Proven implementation expertise with FHIR, CQL, and Da Vinci IGs (CRD, DTR, PAS) aren’t easily found in-house. Additionally, operational leadership skills to coordinate the network processes and exchange between Payer systems, third-party vendors, delegates, and Provider EHRs through FHIR APIs requires specific expertise. 
   
   
2. Procurement & Financial Concerns
   While frozen budgets and competing priorities are common industry-wide, inaction (or delayed action) has a cost: potential CMS penalties and frustration from Providers and Members who expect seamless access, clear PA adjudication, and data exchange.
   
   
3. Vendor Delivery Gaps
   Simply standing up APIs will not solve the complex Prior Auth requirements. Some vendors have promised CMS, but are missing milestones. Use the Vendor Readiness Checklist in our Ultimate CMS Stater-Kit to assess your current progress and ensure your vendor isn’t holding back your progress.
   
   
4. Unclear ROI or Motivation
   If your organization is unsure of the financial or operational benefits, explore our Prior Auth ROI Calculator to quantify how investing in a FHIR and CQL engine that automates PriorAuth, can reduce network costs and significantly improve Provider relationships.
   
   

How to Get Back On Track With Smile

If you’ve identified that your organization will not make the January 1, 2026 milestone, Smile has you covered with our Smile CMS Concierge Services.

With the Smile CMS Concierge Services, we implement, host, and manage your CMS implementation, which includes: 

• Up to 80% of workflows and integrations available out-of-the-box

• Automatic configurations and defined playbooks (built by our FHIR, CQL and Da Vinci IG experts) to accelerate setup

• Custom implementation and on-demand maintenance support from Smile’s technical experts

• Minimal upfront costs and savings of up to US $300,000 annually in FTE maintenance costs

Compliance Delivered Right on Time. Innovation Accelerated.