CMS-0057, Prior Authorization and the Path Forward: How to Align Compliance, Innovation and Strategic Value

By Alix Goss, Senior Consultant, Da Vinci Project Program Manager

By Kendra Obrist, Senior Consultant, Payer Interoperability Expert

For years, the healthcare industry has recognized the inefficiency and administrative burdens of manual prior authorization (PA). While some argue for eliminating PA entirely, automation has long been identified as the more realistic way to reduce burden, speed time to care and support evidence-based decisions. However, widespread adoption has been slow despite the efforts of many payers, providers and technology solution providers. The Centers for Medicare and Medicaid Services’ (CMS) Interoperability and Prior Authorization final rule (CMS-0057) is shifting the focus from theory to real-world implementation. As deadlines approach, organizations are working to ensure compliance while seeking ways to maximize strategic benefits beyond baseline adherence.

It isn’t lost on us that several Health and Human Services (HHS) agencies, including CMS, are experiencing staff cuts and no one knows to what extent they will be or if they will be reversed by the courts. It may be tempting to hedge bets and assume there won’t be enough staff to enforce CMS-0057. Instead of focusing on the compliance aspect, organizations would be wise to focus on the operational benefits, delighted network providers and member satisfaction. Reducing friction isn’t just a great way to achieve cost savings and reduce burden, it’s also a wonderful way to improve brand perception and customer and partner satisfaction.

We can point to the success of early adopters who have already embraced automation, leveraging application programming interfaces (APIs) and enhanced data-sharing capabilities to not only comply with CMS-0057 but also drive measurable improvements in efficiency, burden reduction and patient satisfaction. Time savings, streamlined workflows, and less abandonment of recommended care are becoming tangible benefits rather than distant goals.

However, achieving success isn’t just about technology; it requires payers and providers to align their technology, people, processes and culture to fully realize the potential of automation. The correct approach can turn compliance efforts into a competitive advantage, enabling organizations to reduce burden and cost, improve the patient experience and ultimately allow for provision of better care.

In this article, we’ll explore real-world pilots and successful implementations that offer valuable lessons for the industry. We’ll also highlight how Point-of-Care Partners’ (POCP) unique position at the intersection of policy, standards and strategy makes us the ideal partner to help organizations not only meet compliance deadlines but leverage investments for long-term strategic gains.

Moving Beyond Proprietary Solutions

For years, proprietary approaches and solutions have attempted to address the burden of PA for stakeholders but unfortunately perpetuated inefficiencies and information silos. CMS-0057-F marks a shift toward a standards-based approach using Health Level Seven (HL7®) Fast Healthcare Interoperable Resources (FHIR) APIs and Da Vinci Project implementation guides to enable integrated, scalable data exchange and standardized workflows.

Unlike custom-built systems, standards-based solutions improve interoperability and efficiency for both providers and payers, reducing administrative burden and delays in patient care. By adopting these standards, organizations can ensure compliance while unlocking long-term strategic benefits.

Real-World Pilots: Leading the Way in PA Automation

As the industry moves toward CMS-0057 compliance, several real-world pilots are demonstrating how standards-based PA automation can drive efficiency, improve patient care and reduce administrative burdens. These initiatives provide valuable insights for payers and providers looking to maximize their compliance investments while gaining strategic advantages. POCP has been fortunate to contribute to several of these projects.

Washington State Prior Authorization Pilot

Washington is the first state to mandate FHIR-based prior authorization through its E2SHB 1357, also known as Chap. 382, Laws of 2023, which alters PA requirements for commercial health plans under RCW 48.431 (RCW means Revised Code of Washington). In alignment with CMS-0057, the state is coordinating a large-scale workgroup involving 10+ payer organizations, aiming to streamline PA workflows and ensure compliance with both state and federal requirements. Key elements of the project include:

• FHIR-Based Standards – Implementing such Da Vinci Project implementation guides as those for coverage requirements discovery, documentation templates and rules and prior authorization support to automate PA processes.
• Stakeholder Collaboration – Bringing together payers, providers, technology vendors, subject matter experts and regulators to address both technical and business challenges.
• Phased Implementation – Grouping stakeholders based on FHIR maturity, with more advanced organizations mentoring those earlier in their journey.
  This pilot serves as a model for states and health plans looking to accelerate PA automation at scale.

Regence & MultiCare Collaboration

Under an approved Health Insurance Portability and Accountability Act (HIPAA) exception through the Da Vinci Project, Regence and MultiCare Connected Care embarked to implement real-time prior authorization through FHIR-based APIs. This project dramatically reduced turnaround times, processing 10 to 12 PA requests per hour as compared with 3 to 5 per hour prior to implementation. This collaboration integrated PA automation directly into provider workflows, enhancing efficiency and patient care while demonstrating how health plans and providers can work together to streamline processes using FHIR APIs. This project was so successful that providers referred to the button to initiate the process as “the magic button.” Learn more about this project:

• Press release
• Podcast
• CMS Presentation with statistics

Trebuchet Pilots: HL7 FHIR Transactions in Action

Da Vinci’s Trebuchet pilot program is demonstrating practical use of HL7 FHIR transactions for PA automation and other Da Vinci implementation guides. This initiative effort showcases how implementing FHIR standards can enhance interoperability, reduce administrative friction and improve data exchange between payers and providers. Learn more about this pilot program:

• HL7 blog post
• Trebuchet Playlist on HL7 Da Vinci Project YouTube Channel
• HL7 Da Vinci Project Video Presentations

Massachusetts Health Data Consortium (MHDC) NEHEN 3.0

MHDC is transforming NEHEN, a long-standing regional health data exchange, to add FHIR capabilities to extend their X12 transaction capabilities by adding FHIR-based electronic PA and quality measurement. Their goal is to build a centralized conduit for PA data flow in Massachusetts, connecting payers and providers with a scalable, interoperable solution. This community-driven approach highlights how regional collaborations can support compliance with CMS-0057 while laying the foundation for broader interoperability. Learn more about this project:

• MHDC NEHEN 3.0 Project Page
• MHDC NEHEN FHIR Services

CodeX Prior Authorization for Oncology

The HL7 CodeX Accelerator is tackling prior authorization in oncology, an area in which delays can have critical consequences. CodeX is a multistakeholder organization that brings together providers, payers, healthcare information technology companies, medical associations and others to implement use cases for specialties including oncology, cardiology and genomics. Oncology poses unique considerations such as the need for cancer-specific data elements. To that end, CodeX has developed mCode, a standard FHIR-based element set for electronic health records (EHRs) in cancer care. An active PA in oncology proof of concept focuses on radiation oncology and combines the Da Vinci implementation guides to automate PA workflows with mCode to document a patient’s cancer journey. Future phases will expand automation to medical oncology, offering a blueprint for specialty care PA automation. Learn more about this project by contacting amy.krane@pocp.com or visit:

• CodeX PA in Oncology Confluence Page

Why These Projects Matter

These pilots underscore that CMS-0057 compliance is more than just a regulatory obligation — it’s an opportunity to transform prior authorization processes for long-term efficiency, cost savings and improved patient care. They also foster increased provider-payer partnership in deploying efficient data exchange critical to systemwide productivity. In the next section, we’ll discuss how organizations can take the next step in effectively implementing these strategies.

The real-world pilots we’ve highlighted showcase what’s possible when payers, providers and technology partners work together to implement standards-based, automated prior authorization.

The work being done by these organizations is creating a foundation supporting the ideal future state for prior authorization, whereby:

• Documentation requirements are seamlessly available within EHRs, allowing data to flow without human intervention.
• Automation powered by codified data and clear rules enables technology to instantly approve simple PAs.
• Staff have time to focus on complex cases that require human expertise.

This transformation ensures the actual data reach the right person in a timely manner, in the correct format and at the appropriate point of care, reducing delays in treatment. The goal isn’t just automation for automation’s sake but striking the right balance, using data to automate simple PAs while making complex authorizations as painless as possible.

We’ll now explore some strategic steps you can take to not only meet compliance requirements but gain a competitive edge through intelligent, future-ready automation strategies.

Stay on Track to Achieve Ideal State of PA

Achieving compliance with CMS-0057 is just the beginning. The real opportunity lies in using this mandate as a springboard for broader strategic improvements in prior authorization. However, with projects of this scale, it’s easy to assume everything is on track—only to uncover critical gaps too late. To avoid last-minute surprises, organizations should focus on continuous testing, iteration and industry collaboration to ensure their approach aligns with evolving standards and best practices.

Test, Iterate and Make Progress with Industry Peers

• Engage in industry initiatives like the Da Vinci Project and CodeX to gain insights from early adopters.
• Participate in Connectathons, pilot programs and real-world testing of implementation guides.
• Continuously validate that your technical solutions work as expected before deadlines arrive.

Share Lessons Learned and Success Stories—When Stakeholders Remain Siloed, Progress Slows. Drive Adoption with a User-Centric Approach

• Just because an API is built doesn’t mean it will be used.
• Educate and promote new solutions to ensure widespread adoption.
• Demonstrate clear benefits to stakeholders—providers and staff need to see the value of adoption.
• Learn from others and share your own successes and experiences with implementing Da Vinci Implementation Guides on the Da Vinci in Action Interactive Confluence Page

Adopt a Strategic Approach to Compliance

For organizations looking to take their PA strategy further, POCP offers a unique vantage point at the intersection of standards, policy and implementation. As the program management office for Da Vinci, Gravity Project and FHIR at Scale Taskforce (FAST), active contributors to National Council for Prescription Drug Programs and other standards bodies, and strategic consultants for payers, providers and technology vendors, we help organizations:

• Assess – and potentially modify -- their strategy with an objective lens.
• Navigate the evolving regulatory landscape.

• Make informed decisions to turn compliance efforts into a long-term competitive advantage.

If you’re looking for an expert advisor to help maximize the value of your prior authorization strategy and compliance investments, POCP is here to help. Contact us to arrange time to discuss your CMS-0057 compliance efforts and opportunities.