Policy & operations · 3 min read
Prior authorization: separate the rule from the sales pitch.
Use CMS's primary guidance to ask better questions about payer connectivity and workflow automation.
CMS-0057-F does not create a universal January 2027 software-purchase mandate for physician practices.
Start with who the rule applies to
CMS-0057-F imposes requirements on specified impacted payers, including Medicare Advantage organizations, Medicaid and CHIP programs and plans, and certain exchange issuers. API compliance dates generally begin in 2027, with timing varying by payer type. Other provisions began in 2026. Consult CMS for the applicable requirement and date.
Questions to take into the conversation
- Which payer types and lines of business are in your workflow?
- Which requirement is the vendor's claim referring to?
- Does the claim distinguish APIs from decision-time requirements?
Specify the scope of automation
The rule's prior-authorization API provisions concern items and services, excluding drugs. An API requirement is not proof that a particular vendor connects to your payers or improves your outcomes. Separate eligibility checks, document collection, submission, status tracking, and appeals when reviewing a product.
Questions to take into the conversation
- Which payers and services are supported today?
- What requires staff review or manual portal work?
- How are denials, missing information, and exceptions handled?
Measure operational benefit
Our suggested pilot measures are staff minutes per completed request, turnaround time, rework, unresolved exceptions, and the proportion requiring manual intervention. Define denominators and case mix before comparing results. Track delayed care separately from administrative speed.
Questions to take into the conversation
- What is the baseline for the same payer and service mix?
- Are incomplete requests excluded from the claimed success rate?
- Who owns the queue when automation fails?
Sources & scope
This guide combines HealthIT's suggested evaluation questions with the primary references below. It is educational material; application depends on the specific product, workflow, organization, and jurisdiction.
Found something that needs correction? Send a source-backed correction.