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Understand the CMS Interoperability and Patient Access final rule API requirements for payers

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

Implement a CMS Patient Access API (CMS-9115 / CMS Interoperability Rule) compliant FHIR endpoint that serves member claims, clinical, and formulary data to authorized third-party apps via SMART on FHIR

Build a CMS-0057-F compliant Prior Authorization FHIR API for an impacted payer — endpoint design, data requirements, and compliance timeline

Payer ERA/EFT enrollment for EDI 835 setup

No Surprises Act provider directory 90-day attestation workflow

Type 1 vs Type 2 NPI handling in claims and credentialing systems

Submit a Medicaid/CHIP eligibility inquiry via the CMS FHIR Patient Access API and parse coverage resources

Build a CY2026 hospital MRF JSON file that includes the median allowed amount and percentile fields required by CMS enforcement starting April 1, 2026

Parse a hospital price transparency MRF JSON file to extract payer-specific standard charges and load them into a relational database for analysis

Generate and deliver a Good Faith Estimate (GFE) to a self-pay patient when a service is scheduled 3 to 9 business days in advance under the No Surprises Act

Implement the No Surprises Act open negotiation and federal Independent Dispute Resolution (IDR) workflow for a disputed out-of-network claim

Use the CMS IDR Gateway to manage dispute submissions and monitor dispute status after its launch in the latter half of 2026

Implement HCAHPS patient survey data collection and submission to CMS for the Hospital IQR program via an approved survey vendor

Cross-reference hospital MRF median allowed amounts against payer TiC in-network rates to identify charge-rate discrepancies for price transparency analytics

Configure automated CMS MRF compliance monitoring to detect when a hospital's machine-readable file is missing, stale, or fails schema validation

Implement the No Surprises Act balance billing protections for out-of-network emergency services: detect applicable claims and apply the correct payment calculation

Implement surprise billing protections for non-emergency services at in-network facilities under the No Surprises Act — detect ancillary provider scenarios and manage patient consent requirements

Build a hospital price transparency consumer-facing lookup tool that ingests MRF data and enables itemized service price search by procedure and payer

Implement patient cost estimation using the AEOB (Advanced Explanation of Benefits) data exchange standard when it becomes effective under the No Surprises Act

Implement the CMS Hospital Price Transparency file-naming convention and root-level TXT disclosure file to ensure discoverability by CMS automated monitoring tools

Automate detection of No Surprises Act GFE compliance gaps by auditing scheduling and financial counseling system event logs

Assess CMS-0057 prior authorization API compliance requirements and implement the mandatory FHIR endpoints for impacted payers

Check Medicare eligibility and determine Part A/B coverage using CMS eligibility resources