In a latest survey, 43% of payers and 47% of suppliers stated they haven’t but begun the implementation course of work to satisfy Facilities for Medicare & Medicaid Providers (CMS) interoperability necessities round the usage of FHIR utility programming interfaces (APIs) for prior authorization.
Beginning in January 2026, a brand new CMS mandate requires sooner responses (7-day customary, 72-hour expedited) and particular denial causes, and by March 2026, public reporting of prior authorization metrics to spice up transparency and effectivity. The FHIR API necessities go into impact in January 2027.
In December 2025, the Workgroup for Digital Information Interchange (WEDI) launched outcomes of a latest survey assessing trade readiness to satisfy the necessities of the CMS Interoperability and Prior Authorization Last Rule, also referred to as CMS-0057-F.
With simply over a 12 months till the January 1, 2027 compliance deadline, WEDI stated the brand new survey outcomes exhibit that whereas the trade has made some progress, there may be extra work remaining in implementing, testing, and coaching to satisfy the regulatory necessities. This survey, carried out in October, is a follow-up to the primary one carried out by WEDI in January/February 2025.
CMS-0057-F mandates the usage of Affected person Entry, Supplier Entry, Payer-to-Payer, and Prior Authorization Utility Programming Interfaces (APIs) with the objective of accelerating knowledge sharing to streamline prior authorization and affected person knowledge change. As soon as carried out, these new knowledge change methodologies are anticipated to enhance interoperability and ship much-needed discount in general payer, supplier, and affected person burden.
Key outcomes from the survey embrace:
Payer Responses:
• For the API necessities, 43% haven’t but began their work, in comparison with the earlier results of 50%.
•In estimating the present stage of completion with implementing the Affected person Entry API, 66% estimated they’re 25% or much less accomplished, down from 74%. Twelve % anticipate to be 75% to 100% accomplished by the January 1, 2027, deadline, down barely from 13.5%.
• The bulk (42%) estimate a value of $1 million to $5 million for implementing the API elements of the rule, which was the bulk (35%) response beforehand.
• The highest three implementation challenges they report dealing with are: 1) Digitizing prior authorization insurance policies; 2) Assembly compliance timelines; and three) Delegated third events dealing with challenges connecting with completely different programs. The earlier responses have been: 1) Figuring out a cohesive enterprise technique for interoperability; 2) Digitizing prior authorization insurance policies; and three) Adequate funding.
Supplier Responses:
• Forty-seven % haven’t began implementation and testing, down from the earlier results of 52%, though 47% anticipate they are going to considerably or very probably meet the January 1, 2027, deadline, down from 69%.
• The bulk (55%) stay not sure of the overall price for implementing the necessities and coaching their workers, up from 44%.
• Nineteen % anticipate the clinician to immediately work together with the API prior authorization course of on the level of care with the affected person and 19% anticipate different medical employees to make use of the method. Others anticipated to work together with the method are a referral coordinator at 12.5% and different administrative employees at 25%.
• The highest three implementation challenges reported are: 1) Growing new workflows; 2) Adequate inner experience; and three) Coordinating with distributors/well being plans to check with. The earlier responses have been: 1) Adequate funding; 2) Figuring out a cohesive enterprise technique for interoperability; and three) Finding out the varied networks and the way they interaction (e.g., TEFCA, QHIN, HIE, and so on.).
Clearinghouse Responses:
• For payer prospects, 43% plan to conduct the API knowledge exchanges for them with 57% not sure, in comparison with the earlier outcomes of 62.5% and 31%, respectively. For supplier prospects, 57% plan to conduct the API knowledge exchanges and 43% are not sure, in comparison with 69% and 25%, respectively.
• In estimating the present stage of completion with implementing the Affected person Entry API, 36% estimated they’re 75% to 100% accomplished, up from 12%. Thirty-six % are 25% or much less full, down from 73%.
• In helping payers and suppliers, 66% will help them in complying with the API necessities, down from 84%.
• For the information metrics deadline on January 1, 2026, 47% are 75% to 100% prepared for the reporting, up from 31%.
Vendor Responses:
•Sixty-seven % plan to help payers and suppliers in complying with the necessities, down from the earlier results of 84%.
“With slightly greater than a 12 months earlier than the 1.1.27 compliance date, it’s regarding that 43% of payers and 47% of suppliers haven’t begun their implementation course of. Whereas these numbers are improved from our earlier survey in January/February, they sign that vital work stays for the trade,” stated Robert Tennant, WEDI govt director, in an announcement. “The survey highlights the challenges of shifting to new know-how, modifying workflows, integrating knowledge streams, and digitizing enterprise insurance policies. Within the coming months, WEDI will proceed to evaluate the readiness degree of the trade to satisfy the regulatory necessities and work with impacted stakeholders to transition to thrilling new interoperability options and far wanted prior authorization automation,” Tennant added.
Further survey outcomes:
• When requested about implementing FHIR or each FHIR and X12 requirements, 38% of payers plan to implement solely the FHIR customary and 38% plan to implement each the FHIR and X12 requirements, in comparison with 25% and 39%, respectively, from the earlier survey. The share of “not sure” dropped from 33% to 23%. For clearinghouses, 57% plan to implement each the FHIR and X12 options, down from 81% beforehand.
• Most respondents (68%, up from 61%) have been supportive of staggering implementation of the three prior authorization necessities: Protection Necessities Discovery (CRD), Doc Templates and Guidelines (DTR), and Prior Authorization Assist (PAS), at present all required to be carried out on January 1, 2027. Forty % favored beginning with the CRD, adopted by the DTR after which PAS because the staggered implementation strategy.
• Most suppliers (56%) view having the vast majority of their payers supporting the prior authorization API necessities as extraordinarily essential, up from 41%.
• Forty-four % of suppliers indicated they’re considerably or very more likely to implement the Supplier Entry API, down from 72%.
• All stakeholders recognized that 1) Schooling on trade greatest practices; 2) Schooling on workflow design/modification; and three) Superior schooling (technical) on implementing APIs have been the highest academic sources wanted for implementation of the CMS-0057-F necessities, which was the identical end result from the earlier survey.
