Countdown to Jan. 1, 2027: A CMS-0057-F Refresher for Health Plans

By Integrated Home Care Services
Published October 29, 2026 · Last updated October 29, 2026 · 4-minute read

Key Takeaways

• CMS-0057-F sets firm prior authorization (PA) decision timeframes (72 hours for expedited and 7 calendar days for standard requests), requires specific denial reasons and public reporting of PA metrics, and standardizes the FHIR APIs used to exchange PA information.
• The compliance obligation sits with health plans: Medicare Advantage, Medicaid, CHIP, and QHP-FFE issuers. Traditional Medicare FFS and commercial coverage are outside its scope.
• The rule’s clock stops at the decision. Nothing in the workflow extends to the start of care.

Prior authorization rules for Medicare Advantage, Medicaid, CHIP, and Exchange plans are changing in phases, and two of the deadlines have already passed. Here’s what CMS-0057-F requires, when each piece takes effect, and who has to comply.

CMS-0057-F reconfirms and, where previously absent, sets firm decision timeframes, requires specific denial reasons and public reporting of prior authorization (PA) metrics, and standardizes the Fast Healthcare Interoperability Resources (FHIR) application programming interfaces (APIs) used to exchange PA information. The compliance obligation sits with health plans, and with states for Medicaid and CHIP fee-for-service (FFS) programs. Downstream home care providers are not regulated entities under the rule.

And the rule’s clock stops at the decision. A faster electronic approval does not automatically mean a faster wheelchair delivery, a staffed nursing visit, or an on-time first infusion.

This blog is the first in a three-part series. It covers what CMS-0057-F asks of health plans for durable medical equipment (DME), home health, and home infusion. The next two cover why home-based care calls for precise PA and how a home care benefit manager like Integrated Home Care Services (Integrated) helps plans close the loop from request to start of care.

What CMS-0057-F Asks of Health Plans

The Interoperability and Prior Authorization Final Rule, known as CMS-0057-F, requires FHIR-based APIs for exchanging PA information and recommends HL7 FHIR implementation guides developed through the Da Vinci Project to standardize the round trip of a PA request. In practice, the workflow looks like this:

1. A clinician places an order in the electronic health record (EHR), which triggers Coverage Requirements Discovery (CRD).
2. Through CRD, the EHR asks the payer in real time whether PA is required for that item or service.
3. If it is, the payer supplies, through Documentation Templates and Rules (DTR), a questionnaire specifying the information needed.
4. The EHR prepopulates the questionnaire with data already in the patient’s record.
5. The clinician completes any missing information.
6. Through Prior Authorization Support (PAS), the completed questionnaire and the authorization request are submitted to the payer.
7. The payer approves the request, denies it with a specific reason, or pends it for more information.

The goal is faster decisions with less re-keying and less manual chasing of records. But notice what the workflow depends on: at steps 2 and 3, the payer must already know which services require PA and what documentation establishes medical necessity. The rule standardizes the process, but it does not write the rules that flow through it. Furthermore, nothing in the workflow extends to the start of care.

When Does CMS-0057-F Take Effect?

CMS finalized the rule in January 2024 with a phased compliance timeline:

Already in force:

• Since Jan. 1, 2026: For all covered plans, PA decisions are due within 72 hours for expedited requests and 7 calendar days for standard requests (QHP-FFE issuers excepted), and every denial must include a specific reason.
• By Mar. 31, 2026: Health plans posted their first public PA metrics, covering calendar year 2025.

Still ahead:

• 1, 2027: The Provider Access, Payer-to-Payer, and Prior Authorization APIs must be live, and the existing Patient Access API must include PA information.
• CY 2027 and beyond: For hospitals, the Electronic Prior Authorization measure under the Medicare Promoting Interoperability Program is an optional bonus measure for 2027 and becomes mandatory in 2028. CMS has proposed the same phase-in for clinicians under the Merit-based Incentive Payment System (MIPS), with a final rule expected in November 2026.

Who Does CMS-0057-F Apply To

• In scope: CMS-0057-F applies to Medicare Advantage (MA) organizations, Medicaid (state FFS programs and managed care plans), the Children’s Health Insurance Program (CHIP) (FFS and managed care), and Qualified Health Plan issuers on the Federally Facilitated Exchanges (QHP-FFE).
• Out of scope: Traditional Medicare FFS and commercial coverage are outside its scope.

Obligations are attached by line of business, not companywide. Thus, a payer that operates MA, Medicaid, and commercial lines under one roof must comply for its MA and Medicaid business, but not its commercial book.

Want to see how Integrated delivers CMS-0057-F compliance and utilization management savings without trading one for the other? Let’s talk.

Regulatory References

• Decision timeframes: 42 C.F.R. § 422.568(b)(1)(ii) (7-calendar-day standard); 42 C.F.R. § 422.572(a)(1) (72-hour expedited); parallel Medicaid managed care provision at 42 C.F.R. § 438.210.
• Specific denial reasons and public PA metrics: 42 C.F.R. § 422.122(a), (c).
• Prior Authorization API (effective Jan. 1, 2027): 42 C.F.R. § 422.122(b).
• Provider Access, Payer-to-Payer, and Patient Access API requirements (effective Jan. 1, 2027): 89 Fed. Reg. 8758 (Feb. 8, 2024).
• Regulated entities: 89 Fed. Reg. at 8761; 42 C.F.R. § 431.60 (Medicaid FFS); § 457.730 (CHIP FFS); §§ 438.210, 438.242 (Medicaid managed care); § 457.1233(d) (CHIP managed care); 45 C.F.R. § 156.221 (QHP-FFE).
• Electronic Prior Authorization measure: CMS-1849-F (FY 2027 IPPS/LTCH final rule); CMS-1848-P (CY 2027 Physician Fee Schedule proposed rule, July 14, 2026).