Mastering the CMS Interoperability and Prior Authorization Rule: Navigating the mandate maze
The CMS Interoperability and Prior Authorization Final Rule (CMS 0057 F) is significantly raising the bar for how health plans manage prior authorization. Compliance is now a baseline requirement, mandating FHIR based APIs, standardized clinical terminologies, expedited decision timelines, and public reporting of prior authorization metrics.
While the regulation is designed to reduce administrative burden, accelerate care delivery, and improve interoperability, it requires payers to fundamentally modernize their data infrastructure. The primary challenge lies in enabling standardized information exchange at scale—normalizing fragmented patient data, converting unstructured clinical information into coded formats, managing evolving value sets, and codifying medical coverage policies that drive prior authorization decisions.