For payer organizations, the new CMS prior authorization final rule isn’t a simple compliance checkbox. It’s a real-time audit of your operational readiness, digital infrastructure, and member-facing workflows. The deadline may be regulatory, but the pressure is strategic. And while the rule becomes enforceable in 2026, your clock starts now.
Here’s what you need to understand—and fix—before the lights come on.
What CMS-0057-F Demands (and Why It Matters)
CMS-0057-F requires Medicare Advantage plans, Medicaid, CHIP FFS, and MCOs to significantly improve prior authorization transparency, speed, and interoperability.
Let’s break that down:
- FHIR-Based APIs: You must support bi-directional, real-time data exchange between providers and payers using HL7® FHIR® standards.
- Turnaround Time: You’ll be required to deliver prior authorization decisions in 72 hours for urgent and 7 calendar days for standard requests.
- Documentation Access: Providers and members must have digital access to authorization status and the clinical criteria used.
- Auditability: Every step—from intake to outcome—needs to be tracked, time-stamped, and reportable.
This is about more than technology. It’s about how fast and confidently your organization can operate at scale.
Where Most Payers Are Exposed
Even the best-intentioned teams are being let down by outdated systems that were never designed for this level of transparency and automation. Here are the most common failure points:
1. Fragmented UM Workflows
Manual routing, shared inboxes, and disconnected systems slow everything down. When turnaround time becomes a metric, “we’re working on it” won’t cut it.
2. Limited Visibility
Many payer organizations lack the ability to surface real-time status updates across departments or share them with providers. That’s not just frustrating—it’s non-compliant.
3. Lack of FHIR-Native Infrastructure
“FHIR-compatible” ≠ FHIR-native. If your system wasn’t built for HL7® FHIR® from the ground up, retrofitting will likely fall short.
These gaps don’t just put your compliance at risk. They degrade provider relationships, increase member abrasion, and weaken your ability to lead in managing your population.
How Helios® by Elligint Health Supports Faster Workflows
Smart payers aren’t waiting to rebuild from scratch. They’re layering in modern technology where it matters most—fast, configurable, and purpose-built for the job. Here’s how Helios® helps close the 0057 gap:
Helios® CM
- Connected care management workflows that unify CM and UM
- Real-time visibility into member status and escalations
- Prebuilt task templates and triggers to reduce manual lift
Helios® UM
- Automated, end-to-end prior authorization workflows
- Smart routing, auto-determination, and audit-ready logs
Helios® Hub
- FHIR-native interoperability platform (FiPaaS)
- Converts inbound data into HL7® FHIR® in real time
- Drag-and-drop configuration and two-way API connectivity
Helios® Text and Helios® Go
- Embedded, two-way secure SMS for real-time provider and member updates
- Field-ready access to care data—supporting transparency and engagement
The result? Faster decisions. Smarter compliance. Stronger performance.
What Happens If You Wait?
Every day you delay modernization is another day your team operates in the dark. Once CMS-0057-F goes live, delays, gaps, and manual workarounds become operational issues.
Ready to See Where You Stand?
Download our CMS-0057-F Readiness Checklist to identify gaps—and learn how to fix them before the rule catches up with you.