WEDI Surveys Industry Readiness for CMS-0057-F: What Is the Current State?

Nancy Spector, MSC, WEDI Senior Director, Federal Affairs

In February 2024 when the Centers for Medicare & Medicaid Services (CMS) Advancing Interoperability and Improving Prior Authorization Final Rule, 0057-F as we now know it, was published, the compliance deadline of January 1, 2027, seemed far off in the future. But in just 54 weeks, payers and providers, most with support from clearinghouses and vendors, need to be demonstrating 0057-F compliance. These requirements are not simple updates to existing standards and workflows. These are brand new requirements with widescale implementation of new technology functionalities that bring with them significant business operational changes. And as we all know, this is not the only regulatory work or other implementation priority underway at your organization and throughout the industry.

WEDI has been tracking 0057-F since it was first proposed in December 2020. Since the final rule was released in January 2024, WEDI has conducted numerous education spotlights, events, and conference sessions exploring the application program interface (API) technology, business and technology challenges related to the regulation, payer and provider perspectives, and real-world implementation solutions. (Use the calendar function on the WEDI Events page to thumb back through the education events that have been held.)

Knowing that the 0057-F implementation process would likely have challenges, WEDI developed a survey to track the industry’s readiness and better understand what organizations are facing as they work towards meeting the deadline. A big thank you to the Prior Authorization Subworkgroup co-chairs Janice Bakos (CVS Aetna), Raj Godavarthi (MCG Health) Michael Lunzer (Itiliti Health), Heather McComas (AMA), and the Subworkgroup participants for developing the survey instrument. The first survey was conducted from January to February 2025. Findings from the survey showed that payers and providers were facing significant challenges meeting the requirements with a lack of financial resources and the need to determine a cohesive enterprise strategy as the main concerns.

Survey Results

WEDI repeated the survey in October and, spoiler alert, while the industry has made progress, it is still facing challenges and lagging in their implementation of the requirements. The stakeholder responders to the October survey (48% payers, 14% providers, 5% clearinghouses, and 33% vendors) were a similar distribution as the January/February respondents (45% payers, 21% providers, 9% clearinghouses, and 25% vendors). The following is a breakdown of some of the key results from the October survey:

• The number of both payers and providers that have not started their implementation work decreased between January/February and October. (Payers down to 43% from 50% and providers down to 47% from 52%.) Of concern, almost half (47%) of providers expect to “somewhat” or “very likely” meet the January 1, 2027, deadline, which is a 22 point drop from 69% in the first survey.
• Payers report facing challenges digitizing their prior authorization policies, meeting compliance timelines, and their delegated third parties connecting with different systems. Whereas the top three challenges providers cite are developing new workflows, having sufficient internal expertise, and coordinating with vendors and health plans to test with.
• About half of the clearinghouses report they will conduct the API exchanges for their payer (43%) and provider (57%) customers.
• Two-thirds of the vendors indicate they plan to assist payers and providers in complying with the requirements. Good news, again, for the payers and providers they support.

The survey results, while they might be limited in assessing the entire industry’s implementation status, give us a glimpse into how implementation of 0057-F is proceeding. More than half of payers and providers report having started their work, but what is meant by “started?” Do they have project plans and funding in place? Are they in phase 1 or phase 2 of their project plan? Are they just starting to think about what they need to do? Have they contacted their clearinghouse or vendors? WEDI hopes to address these questions in future surveys.

The following is additional information that was gathered in the survey that will be important for developers and regulators to consider in the upcoming year.

• With much discussion about new prior authorization workflows, in the October survey we found that 19% of providers expect the clinician to directly interact with the API prior authorization process at the point of care with the patient. Another 19% expect that other clinical staff will use the API process, followed by a referral coordinator at 12.5%, and other administrative staff at 25%.
• In the debate of FHIR or FHIR and the X12 278, 38% of payers plan to implement only the FHIR standard and 38% plan to implement both the FHIR and X12 standards. The majority of clearinghouses (57%) plan to implement both the FHIR and X12 278 solutions.
• WEDI also delved into the idea of staggering the implementation of the prior authorization requirements, which 68% of the respondents supported. Of those in favor of this approach, 40% liked starting with the Coverage Requirements Discovery (CRD), followed by the Document Templates and Rules (DTR), and ending with the Prior Authorization Support (PAS). This information has been shared with the CMS regulators, and we will have to wait to see if they act on this.
• Lastly, we asked respondents about what type of resources they would like to have to help them in their work. Education focused on: (i) industry best practices; (ii) workflow design and modification; and (iii) technical components of implementing APIs were the top requests. We know there can never be enough education with this significant type of change. Look to WEDI to provide more education and resources.

You can see more of the survey results here.

We can all agree this is an exciting time with new technology poised to bring meaningful and much-needed improvements to the prior authorization process. However, implementing such sweeping changes is challenging, identifying solutions takes time, and the clock is ticking. WEDI will be repeating this survey in early 2026. We encourage you to participate in it and share your progress towards meeting the January 1, 2027, deadline.