The countdown to the CMS-0057 deadline is on, and payers, providers, and vendors across the industry are all racing to meet the new electronic Prior Authorization (ePA) requirements. As the deadline approaches, one thing has become clear: This is a unique opportunity to rethink how prior authorization should work.
At its core, CMS-0057 aims to reduce administrative burden and improve transparency through standardized, FHIR-based APIs. That sounds straightforward enough, but implementing those standards in the real world has exposed some deep challenges across the ecosystem that compliance alone won’t solve.
Challenge #1: Provider and Payers Speak Different Languages
One of the biggest hurdles is that providers and payers don’t speak the same “language” in the context of clinical and billing codes. Providers work in clinical codes like SNOMED and LOINC, while payers make decisions based on billing codes like CPT or HCPCS.
Bridging that gap here requires a reliable and digital “code crosswalk” that many organizations don’t have today. Without it, even the most advanced FHIR API integration can’t easily connect clinical intent to coverage rules.
Challenge #2: Payer Policies Hidden in Plain Sight
Then there’s the issue of payer policies. Many utilization management (UM) rules and clinical criteria still live in PDFs, spreadsheets, or, in some cases, the heads of experienced staff. To make prior authorization electronic, those policies need to be codified into data that systems can actually interpret. That’s a heavy lift for most organizations, especially when those policies evolve frequently.
Challenge #3: Technical Readiness Gaps Everywhere
Technical readiness is another major barrier.
- EHRs are still catching up on their FHIR API implementations, particularly when it comes to supporting real-time workflows for Coverage Requirements Discovery (CRD) and Documentation Templates & Rules (DTR).
- Payers are working to modernize legacy systems and expose rules that weren’t originally designed to be machine-readable.
- Vendors and UM systems are at varying stages of maturity with regards to CRD, DTR, and Prior Authorization Support (PAS) capabilities.
Focus on Progress, Not Perfection
For payers, the most effective approach may be to start with the parts of ePA that deliver the most immediate value. For example, focusing on CRD can help providers quickly determine whether a service even requires prior authorization, saving time for both sides before a request is ever submitted.
Thinking through the more complex DTR, perhaps the rollout can happen in stages:
- Crawl: Start with a static questionnaire that can be pre-populated with data from the EHR, allowing providers to fill in only what’s missing.
- Walk: Incorporate third-party guideline vendors like MCG or InterQual to automate more of the decision support.
- Run: Digitize policies into dynamic, data-driven questionnaires that fully leverage clinical context for automated decisioning.
Compliance with CMS-0057 is not the finish line, rather a checkpoint on the way to real data exchange transformation. If implemented thoughtfully, the ePA framework can transform prior authorization from a paperwork-heavy process into an intelligent, automated workflow. That means faster decisions, fewer denials, and better experiences for patients and providers alike.
Looking for an Electronic Prior Authorization Partner?
At 1upHealth, we believe the future of prior authorization isn’t just about checking a box. We’re ready to partner with payers, providers, and other vendors across the Prior Authorization workflow to seize this opportunity to meaningfully transform prior authorizations across the industry. To talk to one of our interoperability experts, contact us now.