Trend Report•Healthcare & Life Sciences•
CMS-0062-P and CMS interoperability: Designing prior authorization systems for context-driven care
Mahesh Naphade, Manuel Vera, Yanick Gaudet
CMS-0057-F & CMS-0062-P
Prior Authorization Solutions, Compliance & Enterprise Transformation
With CMS-0057-F and CMS-0062-P, prior authorization is moving to a new operating model — one built around electronic workflows, faster decisions, greater transparency, and interoperable data. The question for organizations across the healthcare ecosystem is no longer simply how to meet the requirements. It is how to build the capabilities once, integrate them properly, and use them to create a more efficient operation for the long term.
Star is a global technology consultancy that delivers interoperability strategy, FHIR/NCPDP engineering, design, and compliance as one motion. Whether you are a payer preparing for CMS-0057-F, a provider modernizing authorization workflows, an EHR vendor building new capabilities, or a PBM navigating the pharmacy-benefit requirements, our prior authorization consulting team helps you move from compliance requirement to enterprise-ready solution.
WHAT'S ACTUALLY REQUIRED
Decoding federal prior authorization mandates
Prior authorization is moving from a largely fragmented, manual process toward an electronic, time-bound, interoperable model. CMS-0057-F is final, while CMS-0062-P is proposed. Keeping those requirements distinct matters for planning, investment, implementation, and executive decision-making.
- Scope: Medicare Advantage, Medicaid, CHIP, &ACA Exchange plans.
- Core Rules: Fast decision timelines (7 days standard / 72 hrs urgent) & clear denial reasons.
- Jan 1, 2026: Faster decisions (7-day standard / 72-hr urgent) & mandatory denial reasons.
- Jan 1, 2027: Full FHIR APIs live (Patient, Provider, Payer & Prior Auth APIs).
- Scope: Medicaid, CHIP & QHP for both drug benefits and Medicare Advantage for medical-benefit drugs.
- Core Rules: NCPDP & FHIR standards integration, real-time coverage checks, and drug PA decisions in 24–72 hrs.
- Oct 1, 2027: Drug ePA live across FHIR (Medical) & NCPDP (Pharmacy) standards.
- 2028: Mandatory public reporting of annual drug PA metrics
MEDICAL & SERVICES BASELINE
CMS-0057-F
What it is: The landmark rule modernizing prior authorization for medical items and services through FHIR APIs.
Timelines
THE DRUG EXTENSION (2027)
CMS-0062-P
What it is: The proposed rule extending electronic prior authorization and transparency requirements directly to drugs.
Timelines
BEYOND THE MANDATE
Compliance is the requirement. Transformation is the opportunity
![Clock, Blue [Set icon 3]](/_next/image/?url=https%3A%2F%2Fcms.star.global%2Fwp-content%2Fuploads%2F2022%2F09%2FClock-Blue-Set-icon-3.png&w=384&q=75){kind=icon}
95%
of physicians say prior authorization delays necessary patient care.
AMA NATIONAL SURVEY
![Enter, Green [Set icon 3]](/_next/image/?url=https%3A%2F%2Fcms.star.global%2Fwp-content%2Fuploads%2F2022%2F09%2FEnter-Green-Set-icon-3.png&w=384&q=75){kind=icon}
79%
say those delays cause patients to abandon treatment entirely.
AMA NATIONAL SURVEY
![Stars, Purple [Set icon 3]](/_next/image/?url=https%3A%2F%2Fcms.star.global%2Fwp-content%2Fuploads%2F2022%2F09%2FStars-Purple-Set-icon-3.png&w=384&q=75){kind=icon}
31%
of prior authorization transactions ran electronically before these mandates.
CAQH INDEX, VIA LEGACY X12 278
The infrastructure required for prior authorization compliance can do more than satisfy CMS requirements. The organizations that approach these mandates as a broader modernization opportunity can build an operation that is more efficient, connected, and sustainable — not simply compliant.
- Reduce manual authorization work and administrative rework
- Improve decision and turnaround times
- Give providers and patients greater visibility into authorization status
- Improve the quality and consistency of exchanged data
- Reduce avoidable denials caused by incomplete information
- Connect medical- and pharmacy-benefit workflows
- Modernize legacy systems and data
- Create an architecture that can adapt as requirements evolve
HOW STAR ENGAGES
One roadmap from readiness to optimization
Prior authorization transformation looks different for every organization. Some need to understand their exposure. Others need to build APIs, modernize workflows, integrate systems, or validate conformance. Star structures the journey around three phases:
01 — Strategic readiness
Understand where you are today and what needs to change.
Star assesses your regulatory exposure, existing architecture, workflows, data, and technology environment to create a practical roadmap toward compliance and modernization.
02 — Build & integration
Turn the roadmap into working infrastructure.
We design and implement the systems, APIs, integrations, workflows, and automation required for your organization—including FHIR, NCPDP, clinical decision support, policy digitization, and prior authorization workflows.
03 — Certify & optimize
Make compliance sustainable.
Validate conformance, test performance, monitor data quality, and optimize the operation after implementation. The objective is not simply to reach compliance once, but to maintain it while continuing to improve performance and experience.
Where do you actually stand against CMS-0057-F and CMS-0062-P?
Star's own readiness model sorts every capability into one of four buckets: already compliant, needs upgrading, must be built, or delegated to a partner. Pick your sector, rate each capability, and see where the gaps sit — about five minutes, and nothing you enter leaves this page.
OFFERINGS BY SECTOR
Prior authorization solutions by sector
Six sectors, one regulatory clock, different exposure.
Prior authorization transformation depends on more than a single API. Star works across the standards and technologies required to connect the ecosystem: FHIR · SMART on FHIR · USCDI · Da Vinci CRD · Da Vinci DTR · Da Vinci PAS · CQL · NCPDP SCRIPT · Formulary & Benefit · RTPB
For organizations evaluating their architecture, Star's healthcare interoperability consulting, prior authorization consulting, and FHIR consulting capabilities bring strategy and implementation together. Our approach can combine FHIR-based Patient Access API, Provider Access API, and Payer-to-Payer API capabilities with the authorization workflows and NCPDP-to-FHIR translation required to connect medical- and pharmacy-benefit data.
Payers carry the primary regulatory responsibility under the federal prior authorization framework. But the technology required for compliance can also become the foundation for a more efficient authorization operation. Under CMS-0062-P, that also means a shift in kind, not just in speed: payers move from financial transactions to clinical ones, processing medication requests, diagnoses, and coverage criteria rather than payment data alone. Star helps payers with:
STRATEGIC READINESS
- Medicaid enhanced funding advisory
- SHOP QHP exception advisory
- Medicaid/CHIP FFS transition advisory (time-sensitive)
- Enterprise compliance roadmap
CORE BUILD & AUTOMATION
- Core interoperability platform (patient access API, provider access API, payer-to-payer data exchange, public provider directory API, drug-PA status bridge)
- Unified prior authorization gateway (prior authorization API – medical benefit, prior authorization API – pharmacy benefit, unified PA orchestration layer)
- Smart benefit routing
- Unified policy digitization
- Automated decision support
- Universal intake gateway
- Step-therapy payer-to-payer reciprocity engine
CERTIFICATION & ONGOING OPTIMIZATION
- Turnaround workflow redesign
- Public metrics & reporting
- Patient privacy & education assets
- Continuous conformance subscription
For providers, prior authorization is ultimately a workflow problem. Manual submissions, incomplete documentation, payer-specific processes, and authorization delays consume staff and clinician time while creating friction around care and revenue. Star helps them with:
READINESS & IMPACT ASSESSMENT
- Workflow impact briefing
- Clinical documentation readiness review
- Data exchange value assessment
- Regulatory harmonization & safe-harbor compliance tracker
INTEGRATION & AUTOMATION
- Compliance rescue track (for organizations behind schedule)
- Point-of-care workflow integration
- Pharmacy-benefit ePA module deployment
- Prescribing workflow harmonization layer
- Drug authorization readiness
- Specimen-timing PA workflow & documentation service
OPTIMIZATION & REVENUE PROTECTION
- Revenue cycle stress-testing
- Appeals & denial management console
- Clinical data integrity audits
- Point-of-care document pre-checks
- MIPS/PI attestation structuring
Your customers' compliance requirements increasingly become product requirements. Star helps EHR and health technology organizations build interoperability and prior authorization capabilities into their platforms—without forcing compliance work to compete indefinitely with the core product roadmap. Our healthcare interoperability consulting and fhir consulting teams can support product strategy, architecture, engineering, conformance, scale testing, and deployment.
PRODUCT & MARKET READINESS
- Regulatory roadmap alignment
- Architecture scoping for drug rules
CORE PRODUCT ENGINEERING
- Accelerated development pods
- Legacy data modernization
- Provider attribution engine
CERTIFICATION, SCALE & WHITE-LABEL DEPLOYMENT
- Conformance pre-testing
- Performance & scale testing
- Client deployment & onboarding services
Prescription drug prior authorization introduces a different technical challenge: medical-benefit and pharmacy-benefit workflows need to work together across different standards and systems. Star helps pharmacies and PBMs build and connect the pharmacy-benefit rail through:
READINESS & GATEWAY ASSESSMENT
- Dual-standard readiness briefing
- Real-time benefit readiness assessment
DUAL-PROTOCOL INTEGRATION
- Dual-protocol orchestration platform (Medical/Pharmacy benefit auto-routing, dual-stream reconciliation Layer – Pilot)
- NCPDP-to-FHIR bridge service
- Automated denial detail engine
ACCURACY & PERFORMANCE ASSURANCE
- Formulary & benefit data validation assessment
- High-volume performance optimization
- Payer-to-payer drug data validation
Organizations that sit between payers, providers, and other participants have a unique opportunity to turn interoperability into a competitive capability. Star supports:
NETWORK & FEASIBILITY ASSESSMENT
- Translation gateway feasibility audit
- Provider portal modernization assessment
NETWORK INTEGRATION & AUTOMATION
- Real-time translation & routing engine
- Portal-to-API modernization
- Cross-payer status normalization
- Multi-transaction platform expansion
PERFORMANCE & SCALE
- Network acale optimization
Drug manufacturers do not control the payer systems at the center of prior authorization, but they are directly affected by delays in access. Star helps market access, patient support, hub, and reimbursement teams improve visibility into the authorization journey through:
STRATEGIC READINESS & COMPLIANCE
- Compliance safeguarding audit
- Brand access requirements mapping (Medical benefit)
- Brand access requirements mapping (Pharmacy benefit)
- Time-to-therapy diagnostics
REAL-TIME VISIBILITY INFRUSTRUCTURE
- Hub platform integration
- Automated access triggers
LAUNCH PERFORMANCE & VISIBILITY
- Real-time access dashboards
- Launch load-testing
WHY STAR?
Healthcare interoperability expertise. Enterprise transformation capability.
Prior authorization sits at the intersection of healthcare regulation, clinical workflows, enterprise technology, and interoperability. Star brings those disciplines together.
Our teams can help you understand the regulatory requirement, translate it into an enterprise architecture, build the required capabilities, integrate them into your existing environment, and validate that they work at scale.
The result is a transformation roadmap grounded in your actual starting point—not a generic compliance checklist.
- Interoperability strategy, standards consulting, implementation, engineering, integration, interface testing, and interface monitoring under one roof.
- Experience integrating with major healthcare systems including Epic, Cerner, Allscripts, and Surescripts.
- Delivery experience across regulated, data-heavy environments and standards including ISO 13485, ISO 27001, IEC 62304, 21 CFR 820, and GDPR.
- Readiness assessments that map what's already compliant, what needs upgrading, what must be built, and what can be delegated to a partner.
MEET OUR EXPERTS
Expertise that moves prior authorization forward
Star’s experts work across healthcare technology, interoperability, regulatory requirements, and enterprise transformation—bringing practical experience to the challenges organizations face as prior authorization evolves.
"Prior authorisation is finally moving from a financial decision to a clinical decision that has financial impact."
Mahesh Naphade
Global Head of Healthcare and Life Sciences at Star
"Payers now have to be very transparent when approving or denying something, and they have to proactively provide as much supporting information as possible as to why they've arrived at that decision. For everyone's sake."
Manuel Vera
Product Manager at Star
"Interoperability is 80% politics and 20% technical work. Having two systems talk to each other is easy, but getting organizations to agree on what data is exchanged and how it's represented and governed over time — that's hard."
Yanick Gaudet
Interoperability Solution Architect at Star
Industry insights and proven playbooks.
Where are you in your prior authorization journey?
Whether you are still assessing your requirements, already building, or preparing for conformance, book a 30-minute consultation with our team to walk through what CMS-0062-P means for your specific environment.
FAQs
CMS-0057-F is the CMS Interoperability and Prior Authorization Final Rule, which requires Medicare Advantage organizations, state Medicaid and CHIP fee-for-service and managed care programs, and QHP issuers on federally-facilitated exchanges to support FHIR-based Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs. Impacted payers must already respond to expedited requests within 72 hours and standard requests within 7 calendar days, and must publicly report prior authorization metrics annually by March 31. Full API compliance is required by January 1, 2027.
