Simple Summary
CMS-0057-F is designed to make prior authorization a fast and more efficient process for providers and payers.
- Replaces manual methods (fax, phone, portals) with electronic processes
- Gives providers faster, clearer decisions and status updates
- Reduces administrative burden for payers and providers
- Helps patients receive care with fewer delays
Who Is Impacted
The rule applies to specific CMS-regulated payers. It does not apply to every health plan, so it is important to distinguish impacted payers from commercial employer-sponsored plans that are outside the rule’s scope.
| Payer Segment | Included entities |
| Medicare | Medicare Advantage Plans |
| Medicaid | State Medicaid FFS + Medicaid Managed Care |
| Children’s Health Insurance Program (CHIP) | CHIP Fee-For-Service (FFS)
CHIP Managed Care |
| Affordable Care Act (ACA) Exchange Plans |
Not included: Traditional Medicare Fee-for-Service and most commercial employer-sponsored plans, including self-funded and Administrative Services Only arrangements, are generally outside the scope of CMS-0057-F.
Payer Requirements
Impacted payers carry the primary compliance obligation under CMS-0057-F. CMS 9115-F Rule, finalized in 2020 and beginning in 2021, required CMS-regulated payers to implement a FHIR-based Patient Access API, establishing the foundation for interoperability. CMS-0057, finalized in 2024, builds on that foundation by expanding FHIR-based data exchange and strengthening prior authorization requirements.
What impacted payers must do
- Implement and maintain FHIR-based APIs that support better exchange of patient, provider, payer-to-payer, and prior authorization information.
- Meet faster prior authorization decision timeframes: 72 hours for urgent requests and 7 calendar days for standard requests.
- Provide clear reasons when a prior authorization request is denied, so providers and patients understand what happened and what may be needed next.
- Publicly report prior authorization metrics, including data that helps show how authorization processes are performing.
For small and mid-sized health plans, these requirements may require meaningful operational change. Legacy platforms, disconnected data, and manual workarounds create compliance risk because the rule expects accurate information, timely decisions, and auditable digital exchange.
Benefits to Payers
| Area | Benefit |
| Operational | Shift from manual workflows to fast, automated, API-first processing. |
| Financial | Reduced administrative costs and rework. |
| Clinical | Better alignment with value-based care models and member experience. |
| Competitive | Digital maturity increases operational efficiency and scalability – a key differentiator. |
Potential Challenges
Compliance will require more than a technology project. Payers must address legacy system constraints, data quality gaps, security requirements, and operational readiness. Integrating policy, technology, workflow, and data governance can be a challenge for some health plans. Those who wait too long may face implementation pressure, staff confusion, avoidable denials, and missed opportunities to reduce administrative burden.
“I know it is a challenging and perhaps overwhelming prospect for many payers who have a spectrum of maturity and understanding regarding the requirements. For providers, the reality of the workflow might be even more confusing and feel out of reach. I would love for SSI to help our clients (and potential clients) better understand the burden reduction opportunity that this regulation provides for them in their industry and individual roles, as well as for their members and patients.” Katrina Parrish, M.D. (Chief Medical Officer, SSI)
Final Thoughts
CMS-0057-F is more than a compliance mandate; it’s a catalyst for healthcare transformation, accelerating the shift from slow, manual prior authorization to faster, digital processes. Payers that modernize can meet compliance requirements while reducing operational friction, improving efficiency, and strengthening provider relationships.
Learn how SSI helps payers improve prior authorization processes and meet compliance, without the IT burden.
