What lessons can payers apply from CMS-9115-F to CMS-0057-F?

The main lesson is that compliance built as a one-off does not produce lasting value. The earlier rule did not fully deliver on broad patient access or greater data interoperability, for several reasons: low member adoption and engagement, uneven maturity in payer data integration and standardization that made sharing usable data hard, ambiguous regulatory guidance, and the difficulty of operationalizing FHIR in legacy systems never designed for it. Many plans invested heavily and still maintain expensive solutions that deliver little beyond the compliance checkbox. The practical implication is to build the second round on a reusable data foundation rather than another conversion-focused extract.

Can payers reuse their CMS-9115-F solution for CMS-0057-F?

Sometimes, but it should be tested rather than assumed. The newer rule is substantially broader, requiring expanded patient access with richer clinical histories, payer-to-payer exchange, payer-to-provider exchange, and prior authorization moved into the provider's electronic health record workflow. Many earlier solutions were built for partial compliance with the previous rule and will not scale to that scope, which can mean a multi-vendor approach or a different turnkey solution. Building around a subscale earlier solution tends to create hidden operational and infrastructure costs that surface later.

How can payers lower the total cost of CMS-0057-F compliance?

Four choices tend to drive cost down. Design the FHIR architecture for enterprise reuse rather than for a single API, which reduces repeated translation and transformation work. Implement modular capabilities that add to one data foundation, so the same investment can serve quality, risk adjustment, and cost of care rather than standing alone. Use partners selectively to complement internal teams instead of attempting a full internal build against a fixed deadline. Insist on a usable data layer, meaning data that is accurate, complete, timely, relevant, versatile, and ready for more than one application.

What business use cases beyond compliance can CMS-0057-F data support?

The data required for compliance is largely the same data other functions already need. Medical and pharmacy claims, encounter data, and lab results can be repurposed for quality and HEDIS reporting, risk adjustment, population health, value-based care analytics, and financial reporting and reconciliation. Making encounter data usable, for example, supports personalized member and provider outreach to close care gaps. Treating the mandate as a modernization trigger rather than a reporting obligation is what turns a required cost into reusable capability.

What is CMS-0062-P and how does it affect CMS-0057-F planning?

CMS-0062-P is a proposed rule released April 10, 2026 that would extend interoperability and electronic prior authorization requirements to drugs, which the 2024 final rule deliberately left out. It was published in the Federal Register on April 14, 2026, with public comment closing June 15, 2026, and most provisions would take effect October 1, 2027 if finalized. It would reuse the same FHIR APIs and foundation built for CMS-0057-F while adding new standards, new reporting, and tighter decision timeframes. The planning implication is direct: plans that build modular, reusable infrastructure for the current rule are better positioned, and plans treating it as a one-time project may end up doing the work twice.

Last Updated on: August 25, 2026

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CMS-0057-F Interoperability and Prior Authorization Final Rule is a Chance for Payers to Rewrite the Playbook for Compliance and Interoperability

Applying lessons from earlier CMS-9115-F interoperability rule

By Gokul Varadharaj, Chief Revenue Officer & Co-Founder
Vincent P. Tumminello, AVP, Solution Strategy
Dmitri Kitaynik, Director, Product Management

By aligning with digital HEDIS and value-based care initiatives, payers can maximize the benefits under CMS-0057-F.

Payers can apply lessons from implementing CMS-9115-F to tackle the significantly more ambitious and complex interoperability and prior authorization final rule, CMS-0057-F. This latest mandate is a golden opportunity for payers to realize strategic value for members, providers, and underlying business performance, value that extends well beyond mandated compliance. This undertaking empowers plans to build towards digital HEDIS for improved quality measurement and value-based care success.

Implementation of its predecessor, CMS-9115-F, did not deliver fully on the mandate’s expected outcomes, namely broad use and adoption of patient access to their health information and greater interoperability of healthcare data, due to multiple factors including:

Low member adoption and engagement
Variable maturity in payer data integration and standardization capabilities that made sharing usable data difficult
Ambiguous regulatory clarity and guidance
Operationalizing FHIR standards in legacy systems not designed to support them

Payers invested heavily to meet the earlier mandate and many plans continue to maintain expensive solutions, but investments have delivered limited business value beyond compliance. With the new CMS-0057-F rule, payers can rewrite their playbooks to achieve compliance at a lower total cost of ownership while driving greater strategic business performance for their organization. Yet, when paired with an interoperable data strategy, CMS-0057-F can fuel continuous quality improvement using digital HEDIS principles.

With the stakes considerably higher in this second round of CMS interoperability, payers have a chance to achieve a value trifecta: Compliance with CMS-0057-F, use case extensibility, and lower total cost of ownership. The key is starting with a flexible usable data foundation.

CMS-0057-F implementation challenges

CMS-0057-F is a mandate with interoperability ambitions well beyond compliance given its scale, scope, and potential to drive improvements in member and provider experience and care delivery. This rule is between 5 and 10 times more complex than CMS-9115-F, with payers up against a 2027 deadline that requires operationalizing Fast Healthcare Interoperability Resources (FHIR) APIs that:

Expand patient access to include richer, clinical histories
Support payer-to-payer electronic data exchange
Support payer-to-provider electronic data exchange
Improve their prior authorization process and move it within a provider’s electronic health record solution

These investments come at a time when payers are facing significant financial headwinds, notably medical loss ratio (MLR) reaching a 13-year high, driven by a combination of increased utilization, higher medical cost trends and overall cost of care. Prioritizing a CMS-0057-F solution that lowers total cost of ownership and optimizes efficiencies is imperative. Implementing a robust interoperable platform can mitigate cost pressures while delivering better member outcomes.

Usable data catalyzes value beyond CMS compliance

The foundation for CMS compliance, broader healthcare data interoperability, and other important use cases is usable data – accurate, complete, timely, relevant, versatile and formatted and ready for any application or use case.

Fortunately, usable data required to operationalize CMS-0057-F, including medical and pharmacy claims, encounter data, and lab results, can be repurposed for use cases beyond compliance such as quality, risk adjustment, and population health/value-based care. To support quality and risk adjustment efforts, for example, making encounter data usable would enable personalized member and provider outreach to close gaps in care. Leveraging that data for digital HEDIS powers risk adjustment and population health in the value-based era.

Best practices for optimizing CMS-0057-F compliance

Given the challenges and opportunities in implementing CMS-0057-F, payers should adopt the following best practices to achieve full compliance while creating opportunities to unlock additional business value and lowering overall total cost of ownership.

1. Evaluate your CMS-9115-F solution. Will your previous investments and internal team be able to scale up to meet the more complex CMS-0057-F mandates? Many solutions were developed to support partial compliance with the CMS-9115-F mandates, but compliance with CMS-0057-F may require a multi-vendor or different turnkey solution. Building around subscale, non-compliant CMS-9115-F solutions is likely to lead to an inefficient solution with hidden operational and infrastructure costs.

2. Maximize FHIR-based architecture. Design and implementation of a FHIR-based interoperability solution should maximize the enterprise potential of this substantial investment and minimize the costs of translating and transforming data into this format. FHIR has a future in healthcare interoperability, so payer IT and operational leaders should align their roadmaps to ensure a cohesive strategy.

3. Seek out expert partners. Many payers don’t have the luxury of time for a completely internal build. Seek partners that complement your internal resources based on prioritization of capabilities that should be nurtured in-house. Consider partners that bring a combination of subject matter and technical expertise and flexibility in their implementation approach. Partners with these capabilities can accelerate the “buy” value of a buy + build strategy with streamlined implementation and faster time-to-business value.

4. Go modular to enable other business use cases. By implementing modular CMS-0057-F capabilities, payers can seamlessly add to the same data chassis, solving for CMS-0057-F compliance while addressing business use cases for quality/HEDIS/Star Ratings, risk adjustment, cost of care and other core organizational functions. This approach to modularity also makes it easier to extend interoperable data exchange via FHIR APIs to commercial plans. This approach delivers the strategic trifecta for complying with CMS rules while optimizing business value: Scalability, extensibility, and affordability.

5. Insist on a foundation of usable data. Instead of continued one-off, conversion-focused extracts, leverage this mandate to modernize the enterprise data foundation and data management. Getting the data layer right makes all the difference in superior technology performance to drive operations and analytics. The premier standard is usable data that is accurate, complete, timely, relevant, versatile, and formatted and ready for specific use cases and applications.

6. Build for long-term competitiveness. Payers that invest in and leverage a more versatile interoperable data foundation can gain market share by reducing expenses and improving provider relationships, member experience and business performance.

By focusing more strategically on achieving value beyond compliance, payers have an opportunity to rewrite their compliance and interoperability playbook to achieve cost efficiency related to CMS-0057-F implementation while simultaneously upgrading their data foundation and interoperability capabilities to unlock innovation and business performance. This strategic view combines compliance with innovation, enabling continuous digital HEDIS improvement and competitive advantage.

Abacus Insights can help payers no matter where they are in their CMS-0057-F journey. Seamlessly achieve compliance with CMS-0057-F, the CMS mandate, at the lowest total cost of ownership and get greater value from your investments.

Abacus Insights’ CMS Interoperability Data Solution

Abacus Insights’ CMS Interoperability Data Solution meets payers where they are in their CMS compliance journey. Built on Abacus’ usable data platform for payers and fully integrated with Onyx CMS interoperability expertise, the solution provides a suite of turnkey compliance modules enabling payers to seamlessly and cost-effectively achieve compliance with the current CMS-9115-F mandate and accelerate implementation and compliance with CMS-0057-F.

Please contact us at info@abacusinsights.com to discuss how we can support your CMS interoperability efforts.

Integrating modern FHIR APIs with interoperable solutions unlocks hidden potential for provider engagement and member experience.

Abacus enables you to harness the power of digital HEDIS and creates a bridge between interoperability and value-based care to achieve superior quality measurement under CMS-0057-F.

Frequently Asked Questions

What is CMS-0057-F, and why does it matter for health plans?

CMS-0057-F is the CMS Interoperability and Prior Authorization Final Rule, which requires impacted payers to operate FHIR-based APIs and to make prior authorization faster and more transparent. CMS released it on January 17, 2024, and it requires Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care entities, and Qualified Health Plan issuers on the Federally Facilitated Exchanges to implement and maintain HL7 FHIR APIs. Operational requirements that took effect January 1, 2026 include decisions within 72 hours for urgent requests and seven calendar days for standard requests, plus specific denial reasons. It matters because the rule is 5 to 10 times more complex than CMS-9115-F, and the deciding factor for readiness is usually the underlying data foundation, not the API layer.

When is the CMS-0057-F compliance deadline?

The core deadline is January 1, 2027, when the required FHIR APIs must be live and operational. CMS phased the rule so that certain provisions applied generally from January 1, 2026, with API development and enhancement requirements due generally beginning January 1, 2027, and exact compliance dates varying by payer type. Reporting started earlier: beginning January 1, 2026, impacted payers must report annual Patient Access API usage metrics to CMS. Payers still in build should treat 2026 as the year for data remediation, because API conformance testing cannot begin until claims, clinical, and prior authorization data are standardized.

Which payers does CMS-0057-F apply to?

CMS-0057-F applies to government-sponsored plans: Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the Federally Facilitated Exchanges. Commercial group and self-insured plans are not directly covered by the mandate. That distinction is a planning opportunity rather than a limit, since a modular FHIR foundation built for the mandated lines of business can be extended to commercial plans without a second build.

How does digital HEDIS relate to CMS-0057-F?

Digital HEDIS runs on the same standardized clinical and claims data that CMS-0057-F forces payers to make FHIR-ready, so one investment can serve both. NCQA is working toward fully digital HEDIS reporting by measurement year 2030 and plans to phase out the hybrid method by MY 2029, which means the medical record chases that prop up today’s rates have a fixed shelf life. Payers that treat CMS-0057-F as a data modernization program, not an API project, can reuse encounter and lab data for quality measurement, risk adjustment, and value-based care rather than funding separate pipelines.

What should payers do first to prepare for CMS-0057-F?

Start by honestly assessing whether your CMS-9115-F solution can scale, because most were built for partial compliance with a narrower rule. From there, three moves matter most: establish a usable data foundation that is accurate, complete, timely, and formatted for reuse; design the FHIR architecture as modules that other use cases can draw on; and decide deliberately what to build in-house versus buy. Building around a subscale earlier solution tends to surface hidden operational and infrastructure costs late, when there is no schedule left to absorb them.