Healthcare payers are racing to meet the new CMS-0057 requirements. But being in compliance with these regulations is only part of the story.
At 1upHealth, we believe these mandates are a launchpad for driving real business value. That’s why our payer product roadmap is designed to not only meet the federal requirements, but also to help payers improve member outcomes, streamline operations, and unlock ROI.
In a recent video, Mohammad Jouni, 1upHealth Chief Product and Technology Officer, detailed how we’re preparing our customers for the future of interoperability. Here’s a closer look at what he covered.
Prior Authorization: A Smarter Path to Automation
By January 1, 2027, impacted health plans will be required to implement APIs that support electronic Prior Authorization (ePA). These APIs must allow providers to submit and track prior authorization requests digitally.
At 1upHealth, we see prior authorization as one of the greatest opportunities to reduce administrative waste in healthcare. Instead of waiting until the mandate takes effect, we’re already onboarding customers and their provider partners into APIs that automate the most common Prior Authorization requests that don’t require manual review.
This approach allows health plans to realize immediate ROI. Providers benefit from faster turnaround times. Plans benefit from fewer phone calls and lower overhead. And both sides gain confidence in scaling digital prior authorization workflows. By the first half of 2026, we’ll expand this support to include full ePA capabilities.
Payer-to-Payer Data Exchange: Closing Gaps in Care
CMS-0057 introduces two major requirements for Payer-to-Payer Data Exchange: outbound and inbound APIs.
- Outbound: When members switch plans or hold concurrent coverage, payers must be able to share data with other insurers. In Q4 of 2025, 1upHealth will expose a handful of customers as Beta users of our outbound APIs, ensuring compliance with incoming data requests.
- Inbound: The bigger opportunity lies with inbound exchange, scheduled for Beta deployment in Q1 2026. With these APIs, payers can pull data from a member’s previous insurer and feed it directly into care management systems. That means faster insights into comorbidities, better support for risk adjustment, and the ability to connect members to the right programs from day one.
This visibility is transformative. Instead of waiting months for a complete picture, health plans can act on critical health information immediately, improving both care quality and efficiency.
Provider Access: Driving Adoption With Better Tools
Another cornerstone of CMS-0057 is Provider Access APIs, which enable clinicians to retrieve data for the patients they’re treating. As of August 2025, 1upHealth already has these APIs live in production with General Availability (GA) by H1 2026.
But we’re not stopping at compliance. Adoption is the real challenge. Historically, Patient Access APIs suffered from low usage because there was little incentive for developers to build on them. To avoid repeating that outcome with Provider Access, 1upHealth is launching a provider-facing web tool in 2026.
This tool will integrate directly with payer portals and identity provider (IdP) systems, making it easy for authenticated providers to retrieve patient data without custom development. The payoff: greater provider satisfaction, increased adoption, and ultimately better patient outcomes.
Patient Access: Simplifying New Reporting Requirements
Starting in 2026, payers must report annual Patient Access API utilization metrics to CMS, segmented by contract or line of business. Preparing for this reporting requirement may seem daunting.
That’s why 1upHealth is releasing a new reporting tool through the 1up Console in Q4 2025. The tool will allow payers to easily generate and export reports that align with CMS requirements. By working alongside customers to configure and segment their data, we’re ensuring compliance is straightforward and stress-free.
Beyond CMS-0057: Building for the Future
Compliance is the floor, not the ceiling. At 1upHealth, our roadmap looks beyond CMS-0057 toward long-term value creation.
- 1up Prior Authorization is designed to reduce costs and generate ROI through automation.
- 1up Payer-to-Payer Data Exchange creates pathways to accelerate risk adjustment and improve member care.
- 1up Provider Access ensures adoption through intuitive tools that reduce friction for clinicians.
- 1up Patient Access reporting in the 1up Console provides clarity and ease of use so customers can stay ahead of regulatory obligations.
And while our immediate focus is on delivering CMS-0057, our engineering teams are already exploring new frontiers in analytics, AI, and advanced data sharing. Our goal is to maximize the value of every compliance-driven investment, creating a stronger, more connected healthcare system.
At 1upHealth, we’re here to make CMS-0057 compliance simple, scalable, and ROI-positive. Watch the full video to hear directly from CPTO Mohammad Jouni on our Payer Product Roadmap and how we’re building for the future or reach out to schedule time for us to walk you through the plan.