Ready for the CMS interoperability rules
The CMS Interoperability and Prior Authorization rule (CMS-0057-F) requires Medicare Advantage, Medicaid, CHIP and exchange plans to run four FHIR APIs by January 1, 2027, and to decide prior authorizations faster from 2026. We get plans ready, then use the data those APIs open up.
Why it matters
The dates are fixed
Prior authorization decision timeframes apply from January 1, 2026: 72 hours for urgent requests and 7 calendar days for standard ones. The four APIs follow from January 1, 2027.
Medicaid is fully in scope
State Medicaid and CHIP programs, fee-for-service and managed care, must comply alongside Medicare Advantage organizations and exchange plans.
Data is only useful when it is clean
APIs move data. Matching members, standardizing codes and removing duplicates is what makes it usable for care management, quality and cost.
How we work
Assess the gaps
Against each requirement: Patient Access, Provider Access, Payer-to-Payer and Prior Authorization APIs, decision timeframes and public reporting.
Build and connect
FHIR APIs built on the HL7 Da Vinci implementation guides, delivered with your existing vendors.
Test, report and run
Conformance and end-to-end testing, annual public reporting of prior authorization metrics, and support after go-live.
What the work covers
- CMS-0057-F and CMS-9115-F gap assessment
- Patient Access, Provider Access and Payer-to-Payer APIs
- Prior Authorization API (Da Vinci CRD, DTR and PAS)
- Member matching and data quality
- Prior authorization metrics and public reporting
- Clinical data exchange with providers and HIEs
Common questions
Have a question that is not here?
Ask our teamWho has to comply with CMS-0057-F?
Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans, and Qualified Health Plan issuers on the federally facilitated exchanges.
What are the key dates?
Most operational provisions, including prior authorization decision timeframes, apply from January 1, 2026. The API requirements apply from January 1, 2027; for Medicaid and CHIP managed care, from the rating period that begins on or after that date.
Do you replace our technology vendors?
No. We plan the program, fill the gaps between vendors, and test the result end to end, so the parts work together.
What happens after go-live?
The APIs need monitoring, the prior authorization metrics are reported publicly every year, and the implementation guides keep changing. We can run that with your team.
Measurable P&L impact. Every time.
Across medical expense, administrative cost, and risk-adjusted revenue, our focus is the same: AI must translate into financial results, not just another pilot or technology deployment.
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