Beyond Compliance: Building a Modern Prior Authorization Ecosystem

Health plans are entering a critical period as the CMS Interoperability and Prior Authorization Final Rule (CMS-0057) begins taking effect in 2026. The rule requires payers to stand up FHIR-based APIs, improve data access, and streamline prior authorization workflows. In parallel, CMS is encouraging organizations to join its Health Tech Ecosystem “pledge,” signaling that the agency expects plans to advance burden reduction and data exchange beyond the regulatory minimums.  

These initiatives — layered on top of ongoing priorities around provider collaboration and member experience — have created an inflection point. Compliance will lay the foundation for modernizing prior authorization, but the real opportunity is for payers to use this moment to strengthen coordination across organizations and introduce technology that supports seamless, bi-directional data exchange.

Progress is challenging because prior authorization touches so many organizations and systems. It is a chain of interconnected steps, handoffs, and information exchanges involving payers, providers, EMRs, health IT vendors, clearinghouses, delegated entities, data networks, and increasingly, AI-enabled tools. Without true coordination and commitment to sustained change, even the best-designed improvements fail to take root. Because no single organization can fully see how all these systems interact, essential operational knowledge often remains siloed. Much of it sits behind each entity’s internal “front door,” making it difficult to coordinate meaningful, lasting interoperability.

Barriers Payers Face in Improving Prior Authorization

Realizing positive change in prior authorization is not as simple as following a recipe. Positive change necessitates rethinking the ways payers and providers work through prior authorizations today. It also requires updates to systems and reinvestments in technology. This will not be a simple “flip of the switch” transition. Payers and providers will need to close out prior authorization requests initiated before FHIR-based APIs were introduced while simultaneously adopting the new APIs and associated workflow modifications. 

Fragmented system architecture may pose additional challenges. Some providers operate on a single EHR that manages administrative, financial, and clinical needs; others have a best-of-breed approach or multiple integrated systems. Payers may separate claims, benefits, eligibility, utilization management, and policy functions across different platforms, creating integration and access hurdles. For example, documentation requirements may be implemented differently across benefit plans, where one plan may require more detailed documentation than another for the same item or service. 

Data governance and provenance play a key role in data quality, particularly when several independent organizations conduct data exchange, such that data quality enhances rather than impedes positive change. As with any transformation that spans subject matter experts, workflow users, and IT teams, consistent interpretation of requirements, clear policy definitions, and well-designed automation (supported by validation and ongoing monitoring) also play roles in realizing the full value of prior authorization advancement. To complement this, resilient change management that accounts for the impact to or from external partners in interoperability has now become even more necessary with increased interdependency – leading to impact on payers, practitioners, care givers and patients.

The Roadmap to Driving Lasting Operational Change

Payers can take several practical steps to translate CMS-0057 requirements into long-term improvement:

• Make new tools genuinely useful for providers 

Payers should work directly with in-network providers to ensure new tools eliminate unnecessary phone calls, emails, and back-and-forth attempts to track down authorization status or documentation. Embedding prior authorization prompts into clinical decision support can significantly alleviate the inefficiencies and frustrations associated with today’s processes. 

• Use CMS-0057 infrastructure as a reusable foundation

FHIR-based APIs built for compliance can be designed for reuse across multiple authorization types and workflows. This approach turns a regulatory mandate into shared infrastructure that supports expanded automation and broader clinical data exchange.

• Leverage incentives to reinforce burden reduction

Payers can link incentives to measurable improvements in the prior authorization process. These incentives can offset the temporary burden for providers and may be funded by savings generated from more efficient workflows. 

• Strengthen internal alignment and data governance

Accurate, consistent data is essential for streamlined prior authorization. Aligning clinical, IT, utilization management, compliance, and network teams around shared workflows and policy logic ensures that data exchanged through APIs is reliable — improving both automation and provider trust.

Establishing this foundation will help ensure that compliance efforts become the basis for durable modernization, rather than short-term regulatory exercises. 

What’s Next: A Higher Standard for Prior Authorization

Compliance should be viewed as the starting point — not the finish line — for prior authorization modernization. As early adopters demonstrate tangible burden reduction, improved transparency, and stronger provider satisfaction, clinicians and EMR vendors will take notice. They will begin to expect similar performance from other plans, raising the bar across the industry.

In this way, the organizations that move first and treat compliance work strategically will establish a meaningful competitive advantage. They will shape expectations, influence the pace of industry-wide improvement, and ultimately help create a more consistent, collaborative, and efficient prior authorization environment for everyone.