The CMS Mandated Shift to Data Transparency and Accountability
All U.S. Payers must publish their Prior Authorization (PA) metrics on their public websites by March 31, 2026, using data from Measurement Year (MY) 2025, as required under the CMS-0057-F Rule. The rule mandates health plans to execute a fundamental reset of their data and prior authorization processes, moving from static, manual reporting to real-time operational accountability and transparency.
Payers must ensure that all required prior authorization data from MY 2025, from provider EHRs, internal systems, and delegated entities, is consistently captured, validated, and reportable. This requires unified FHIR data management, and without it, Payers will risk non-compliance, penalties of up to $1,000 a day, and low member and provider satisfaction scores. Data transparency and interoperability at the level required by CMS-0057-F represent a new standard for the healthcare ecosystem. With less than six months remaining to ensure that all MY 2025 data is accurately captured and reportable, Payers can use this checklist below to assess their progress and identify any remaining gaps.
Prior Authorization (PA) Metrics Reporting Checklist for Payers
Have you been consistently capturing all required MY 2025 data, including approvals, denials, decision times, denial reasons, etc., since January 1, 2025? (Note: the first public report relies on a full year of data.)
Do you have visibility into where all relevant data resides across your systems, including legacy platforms, delegates, third-party administrators / UMs and BHs (Utilization Management and Behavioral Health vendors) environments?
Have you established the necessary pipelines to collect, normalize, and aggregate data from multiple sources into a unified dataset?
Have you confirmed that all delegated entities (such as UM & BH vendors, IPAs, or TPAs) are tracking and sharing complete 2025 data? If not, is there a plan or contract in place to receive a comprehensive data extract in early 2026?
Has a webpage been scoped, designed and assigned for publishing the PA metrics, aligned with CMS visibility and accessibility requirements?
Is there a designated owner responsible for overseeing report accuracy, publication, and annual updates?
If your organization hasn’t started, or is stalled in its efforts, there is still time to meet the March 2026 milestone.
The CMS-0057-F Rule requires a complete transition from manual, paper-based or hybrid prior authorization workflows to electronic, FHIR®-enabled systems that integrate directly with provider EHRs. This shift is not minor. It requires implementing the four FHIR APIs, modernizing legacy data flows, and coordinating operations across the entire Payer network, integrating with all third-party systems and Provider EHRs. It also requires data transparency and public reporting. While several large payers are well underway, others remain early in the process and are facing predictable roadblocks.
Smile CMS Concierge Services help Payers overcome these challenges with proven implementation strategies.
Where Payers Are Stalled…
Limited Internal Capacity:
Unclear Data Landscape:
Overlooked Delegated Entities:
…And How Smile Is Helping Payers Progress
Expertise on Demand:
Through Smile CMS Concierge Services, we provide:
• Custom implementation and configuration
• On-demand maintenance and technical support from Smile’s interoperability experts
Accelerated Implementation:
• Up to 80% of workflows and integrations available out-of-the-box
• Predefined configurations and playbooks built by Smile’s technical experts to accelerate setup and reduce errors
Seamless Integration:
• FHIR-Based Data Integration, which consolidates clinical, claims, and administrative data across systems and delegated entities for seamless interoperability and scalability.
• Operational Efficiency, which streamlines prior authorization workflows and payer-to-payer exchanges, while cloud-ready managed services reduce infrastructure costs and vendor complexity.
With Smile CMS Concierge Services, we implement, host, and manage your CMS compliance strategy. With it, you get minimal upfront CMS implementation costs, and savings of up to US $300,000 annually in FTE maintenance costs.