CMS-0057-F is the Prior Authorization Interoperability Rule, requiring health plans to implement digital prior authorization (PA) application programming interfaces (APIs). The rule mandates 72-hour response times for expedited decisions and 7-day response times for standard decisions. Plans must accept PA requests through standardized digital channels, reducing the time patients and providers spend waiting for authorization decisions.
This rule applies to Medicare Advantage plans, Medicaid managed care organizations, Children's Health Insurance Program (CHIP) plans, and qualified health plan issuers on the Health Insurance Marketplace. The requirements also extend to group health plans that offer coverage to enrollees. Organizations with fewer than 50 employees have delayed compliance dates for certain technical standards.
The compliance deadline for digital PA channels is January 1, 2026. Plans must transition to full FHIR-compliant APIs by January 1, 2027. CMS enforces compliance through regulatory audits and plan oversight. Non-compliance can result in corrective action plans, civil monetary penalties, and plan exclusion from federal programs.
Any request for authorization before a service is rendered that triggers your PA policy. This includes initial requests, reauthorization, and continuation of therapy decisions.
Self-insured group plans are covered by this rule. The requirements apply to all health plans that meet the definition of a health plan under the rule's scope.
CMS may impose corrective action plans, suspend plan enrollment, and assess civil monetary penalties. Federal program exclusion is possible for persistent non-compliance.
Prior Authorization Rules | Medicare Advantage Authorization | CO-197 Not Authorized | CO-50 Service Denied
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