3 Key Highlights from 1upHealth’s 2025 Payer’s Guide to Interoperability

With the January 1, 2027 compliance deadline for the Interoperability and Prior Authorization final rule (CMS-0057) fast approaching, payers have much to accomplish. Your list includes updating Patient Access APIs, implementing new FHIR API functionality for payer-to-provider and payer-to-payer data exchange, and setting yourself up for success with electronic prior authorization (ePA).  

While there’s real work ahead, there’s also real opportunity. Beyond satisfying regulatory requirements, successfully implementing the CMS APIs will enable the real-time exchange, standardization, and analysis of claims and clinical data that can be used to drive insight, action, and improvements in areas like risk adjustment, care management, and member and provider engagement.

To help you navigate your organization’s journey to CMS-0057 compliance and beyond, we’ve put together a 2025 Payer’s Guide to Interoperability. 

Here’s a look at 3 key highlights from the guide:

#1 CMS-0057 Snapshot: What You Need to Know

CMS-0057 is a complex rule with significant technological, operational, reporting, and timing requirements. The following APIs are required:

• Patient Access API: Makes it easier for individuals to access and use their health data, ultimately supporting more informed care decisions.
• Provider Access API: Makes it easier for payers to share member data with in-network providers, ultimately improving care coordination. 
• Payer-to-Payer Data Exchange API: Makes it easier for payers to exchange member data with their current and concurrent payers, ultimately improving member care.
• Prior Authorization API – Makes it easier for providers to submit prior authorization requests and receive timely responses, ultimately reducing provider burden and improving member care.

Download the guide for in-depth detail on each API requirement. 

#2 The Tech Foundation Needed: A Health Data Management Platform

To thrive in the new era of health data exchange, payers need more than disparate APIs – they need a Health Data Management Platform (HDMP). 

At its core, a HDMP acts as the conductor of data in motion, seamlessly managing the flow of clinical and claims information across the healthcare ecosystem. With critical elements like data governance, security, consent, privacy, and access management, HDMPs form the backbone for computable interoperability.

While initially developed to enable the transactional movement of data, HDMPs have evolved to support additional and more strategic use cases and have radically changed the types of insights that can be delivered across healthcare. 

Download the guide to learn more about HDMPs. 

#3 Checklists: Setting Your Organization Up for Success

Your team will need to assess your data, define your member engagement strategy, and align your teams on network systems to ensure a smooth and compliant rollout. We’ve developed the following detailed checklists to help you set your organization up for success:

• Assessing your data
• Defining your member engagement strategy
• Aligning your teams

Download the guide for access to these detailed checklists. 

Why the Interoperability and Prior Authorization final rule (CMS-0057) is so important

With CMS-0057, CMS is ultimately requiring payers to have a toolkit to hasten data availability, data exchange, and computable interoperability in healthcare. These elements are foundational to solving the challenges that have long-plagued the industry – including high costs, poor quality, and massive inefficiencies – using technology in a cohesive, thoughtful, sustainable, scalable way. 

We believe that the winners in this new era of health data exchange will be those that bring a “Compliance-plus” mindset, ensuring compliance while maximizing the value of their investment by putting all of this newfound, real-time data to work to power a multitude of use cases for strategic advantage and better decision-making in areas like risk adjustment, quality management, care management, and provider and member engagement. 

Please download the ebook to learn more or reach out if we can be of any assistance.