Understand CMS Prior Authorization rule (CMS-0057-F) API compliance requirements and implementation timelines

Verified steps

1. Review the CMS Prior Authorization Final Rule (CMS-0057-F) on cms.gov to identify the three new mandatory FHIR API requirements: Prior Authorization API for members, Prior Authorization API for providers, and reporting metrics requirements.
2. Understand the Prior Authorization API for members: payers must expose prior authorization status, supporting documentation requirements, and denial reasons to members via their Patient Access API FHIR endpoint.
3. Understand the Prior Authorization API for providers: payers must implement a FHIR-based prior authorization API (aligned with Da Vinci PAS) for providers to submit prior authorization requests electronically starting on a CMS-defined compliance date.
4. Review the specific compliance dates in CMS-0057-F for each API type and impacted payer category — note that compliance dates vary and some are after 2025; verify current dates from cms.gov as they may be subject to regulatory updates.
5. Review the prior authorization decision time requirements: CMS-0057-F specifies maximum decision turnaround times for standard (non-urgent) and urgent prior authorization requests that payers must meet.
6. Identify the reporting requirements: payers must report annual metrics on prior authorization approval rates, denial rates, decision times, and appeals to CMS for public transparency.