CMS-0057-F: What’s Changing Next
and What Health Plans Should Focus On Now
CMS is closing the gaps in prior authorization with more automation, stronger standards, and greater transparency—across all drugs, all programs, all payers.
The Big Picture: CMS Is Closing the Gaps
The Problems
Prior authorization is too manual in many areas.
Drug approvals are slower and less standardized.
Payers and providers do not exchange data consistently.
It is difficult to track and measure prior authorization performance.
The Solution: This Rule Drives
More Automation
Electronic prior authorization becomes the default.More Transparency
Stronger reporting and visibility into PA performance and outcomes.More Standardization
Consistent digital workflows and interoperability standards.More Accountability
Consistent reporting across payers and programs.Key Updates in the Proposed Rule
1
Electronic PA Expands to Include Drugs
- Electronic PA required for all drugs.
- Medical benefit drugs via electronic PA.
- Pharmacy benefit drugs via established pharmacy standards.
2
Two Standards, Depending on Drug Type
- FHIR for medical benefit drugs.
- NCPDP for pharmacy benefit drugs.
- Plans must manage two parallel workflows.
3
More Transparency & Reporting Requirements
- Report API usage metrics.
- Publish PA performance and drug-related metrics.
- Provide detailed denial reasons.
- Track approvals, denials, and extensions.
4
APIs Become More Central to Everything
- Patient Access, Provider Access, Payer-to-Payer, Prior Authorization, and Provider Directory APIs.
- Expose status, timelines, denial reasons, approved drugs, dosage details, and supporting clinical documentation.
5
Standardization Is Tightening Again
- Move to updated, non-expired FHIR standards.
- More implementation guides become required.
- Older standards like X12N 278 phase out over time.
6
Endpoint Transparency Is Mandatory
- Payers must report API endpoints and technical details.
- CMS will publish endpoint information centrally.
- Connections become easier for providers, vendors, and developers.
What This Means for Health Plans
Fully digital prior authorization across medical and pharmacy benefits.
Stronger coordination across medical, pharmacy, IT, and compliance teams.
Reporting requirements become more detailed and more visible to the public.
API infrastructure becomes the core system of record for utilization management.
Vendors and PBMs play a larger role—but accountability remains with the plan.
Timing matters: some reporting requirements begin earlier, but full implementation timelines extend into 2027 and beyond. Start preparing now.
How PAHub Helps You Stay Ahead
Transition from manual to electronic prior authorization workflows.
Support FHIR-based interoperability requirements.
Automate UM processes to meet faster decision timelines.
Improve visibility into PA performance and reporting.
Streamline payer-provider communication, including denial reasoning workflows.
