Beyond CMS-0057-F compliance: How payers can reduce prior authorization friction before the 2027 deadline

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Beyond CMS-0057-F compliance: How payers can reduce prior authorization friction before the 2027 deadline

Capgemini

Sep 29, 2026

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As health payers in the US prepare to comply with the CMS-0057-F (CMS Interoperability and Prior Authorization Final Rule) by January 2027, the administrative friction may remain for both payers and providers well after implementation.

While the regulation focuses on transparency of PA requirements, including coverage discovery, procedure-specific policy guidelines, and data transfer between providers and payers, it addresses only part of the problem. Another limitation is that, for now, the compliance requirement applies only to specific categories of CMS-regulated payers, rather than to all health plans. In addition, adoption is not mandatory for all providers, except for certain providers eligible for the Merit-based Incentive Payment System (MIPS).

The readiness gap is already visible

The provider and payer communities are not fully prepared for the upcoming deadline, according to WEDI’s 3rd Interoperability and Prior Authorization Survey.1 WEDI’s findings show that provider confidence in meeting the 2027 deadline has fallen to 25%, while the providers’ intent to implement also declined to 33% in February 2026 from 44% in October 2025.

From the payer’s perspective, the survey shows that 10% of payers haven’t even started interoperability-specific work. Moreover, only 16% of payers are currently around 100% complete ahead of the January 2027 deadline.

The top three challenges facing payers are implementation and compliance costs, operational readiness, and execution gaps.

Even after implementation, the administrative burden associated with PA decision-making is likely to persist on the payer side. This is especially true for complex cases, which often require evaluation of multiple clinical documents and additional evidence-based follow-ups. These interactions typically occur through multiple channels, leading to delays and incomplete responses from providers. As a result, this ongoing friction can continue to drive dissatisfaction among both providers and members.

Three dimensions for improving prior authorization

Capgemini sees three mutually reinforcing dimensions for prior authorization transformation: interoperability, automation, and collaboration. Together, they can help transform prior authorization from an administrative checkpoint into a more timely, transparent, and clinically informed exchange.

1. Interoperability: Payers should view CMS-0057-F compliance as the foundation for broader prior authorization rather than the final destination. Coverage discovery, documentation requirements, request submission, status tracking, requests for additional information, and decisions should connect seamlessly with the systems where payer and provider teams already work.

2. Automate administrative review: Responsible AI can streamline prior authorization intake by identifying administrative gaps early and communicating them to providers before the request moves further into review. Document AI and computer vision can analyze incoming materials, identify the requested service, extract diagnoses and clinical observations, detect missing pages, and map supporting evidence to FHIR resources or payer data models.

• Evidence-based AI review: Responsible AI can strengthen prior authorization reviews by evaluating clinical documentation against applicable medical policies and coverage criteria. AI agents can generate evidence-based recommendations supported by a clear rationale, documented findings, and an auditable trail of how each recommendation was developed.

Eligible procedures that meet predefined, payer-approved criteria may be automatically approved, allowing clinicians to focus on complex cases that require medical judgment, while retaining oversight and final decision-making authority.

PHI and PII protection should be built into the workflow, including data minimization, de-identification, or tokenization where feasible, access controls, audit logging, and safeguards to ensure information is protected before it is processed by a generative AI model.

3. Payer-provider collaboration: When a prior authorization request does not initially meet authorization requirements, payers should engage providers early rather than defaulting immediately to a denial. Structured collaboration between payers and providers can help clarify clinical intent, resolve documentation gaps, and support more accurate authorization decisions. This active dialogue can also help identify the most appropriate pathway to care.

Such collaboration helps clarify missing clinical information, identify supporting documentation, and, when appropriate, explore alternative evidence-based treatment pathways through specialist-led clinical consultation. A modification-over-denial approach helps providers align requests with clinical guidelines while allowing payers to maintain standards for medical necessity, quality, and cost-management.

This elevates prior authorization from a purely administrative process to a clinically informed exchange in which patient-specific provider insights are considered alongside evidence-based guidelines and payer policies.

What payer leaders should do now

As health plans prepare for the 2026 and 2027 CMS-0057-F milestones, the focus should extend beyond implementation activities. Actions taken now can help establish the operational, clinical, and governance foundations needed for long-term success.

Right now, payer leaders should:

• Create one roadmap across the 2026 operational requirements and 2027 API requirements

• Define the target operating model, including decision rights, exception paths, clinical oversight, and third-party responsibilities

• Digitize and govern medical policies so requirements, evidence, and denial reasons are applied consistently

• Prioritize provider journeys from discovery through follow-up

• Measure outcomes beyond go-live, including cycle time, administrative touchpoints, avoidable denials, provider experience, and member access.

Turning a mandate into measurable results

The payers that lead in this next phase will not be those that simply expose the required APIs, but the organizations that turn interoperability into operational intelligence, responsible automation, and stronger clinical collaboration.

Capgemini can help health payers assess their CMS-0057-F readiness. This includes modernizing interoperability architecture, redesigning utilization management workflows, and applying responsible AI to reduce administrative burden. Clinical oversight and regulatory confidence remain built into the process. The next step is to define how the mandate can serve as the foundation for a practical, sequenced transformation roadmap with measurable business outcomes.

Start with a readiness-to-transformation roadmap

Ready to move from CMS-0057-F compliance planning to prior authorization transformation? Contact Capgemini for a readiness assessment and executive roadmap workshop. Together, we can define a practical transformation path spanning interoperability, operating model modernization, responsible AI, and provider experience.

References

• WEDI Interoperability and Prior Authorization Survey

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Troy Awsumb

Global Healthcare Industry Lead

Troy has nearly two decades of experience transforming the operating capabilities of businesses in the healthcare ecosystem. As the Global Industry Lead for Healthcare, he uses his expertise to develop insights and solutions that weave together business models, technology, data, and operations. As a thought leader he works with payers, providers, retail health, technology firms, startups, and PE/VC firms.

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