Survey Highlights Challenges of Interoperability and Prior Authorization Rule

In a recent survey, 43% of payers and 47% of providers said they have not yet begun the implementation process work to meet Centers for Medicare & Medicaid Services (CMS) interoperability requirements around the use of FHIR application programming interfaces (APIs) for prior authorization. 

Starting in January 2026, a new CMS mandate requires faster responses (7-day standard, 72-hour expedited) and specific denial reasons, and by March 2026, public reporting of prior authorization metrics to boost transparency and efficiency. The FHIR API requirements go into effect in January 2027. 

In December 2025, the Workgroup for Electronic Data Interchange (WEDI) released results of a recent survey assessing industry readiness to meet the requirements of the CMS Interoperability and Prior Authorization Final Rule, also known as CMS-0057-F. 

With just over a year until the January 1, 2027 compliance deadline, WEDI said the new survey results demonstrate that while the industry has made some progress, there is more work remaining in implementing, testing, and training to meet the regulatory requirements. This survey, conducted in October, is a follow-up to the first one conducted by WEDI in January/February 2025. 
 
CMS-0057-F mandates the use of Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization Application Programming Interfaces (APIs) with the goal of increasing data sharing to streamline prior authorization and patient data exchange. Once implemented, these new data exchange methodologies are expected to improve interoperability and deliver much-needed reduction in overall payer, provider, and patient burden. 
 
Key results from the survey include:
 
Payer Responses:
• For the API requirements, 43% have not yet started their work, compared to the previous result of 50%.
•In estimating the current stage of completion with implementing the Patient Access API, 66% estimated they are 25% or less completed, down from 74%. Twelve percent expect to be 75% to 100% completed by the January 1, 2027, deadline, down slightly from 13.5%. 
• The majority (42%) estimate a cost of $1 million to $5 million for implementing the API components of the rule, which was the majority (35%) response previously.
• The top three implementation challenges they report facing are: 1) Digitizing prior authorization policies; 2) Meeting compliance timelines; and 3) Delegated third parties facing challenges connecting with different systems. The previous responses were: 1) Determining a cohesive enterprise strategy for interoperability; 2) Digitizing prior authorization policies; and 3) Sufficient funding.
 
Provider Responses:
• Forty-seven percent have not started implementation and testing, down from the previous result of 52%, although 47% expect they will somewhat or very likely meet the January 1, 2027, deadline, down from 69%.
• The majority (55%) remain unsure of the total cost for implementing the requirements and training their employees, up from 44%.
• Nineteen percent expect the clinician to directly interact with the API prior authorization process at the point of care with the patient and 19% expect other clinical staff to use the process. Others expected to interact with the process are a referral coordinator at 12.5% and other administrative staff at 25%. 
• The top three implementation challenges reported are: 1) Developing new workflows; 2) Sufficient internal expertise; and 3) Coordinating with vendors/health plans to test with. The previous responses were: 1) Sufficient funding; 2) Determining a cohesive enterprise strategy for interoperability; and 3) Sorting out the various networks and how they interplay (e.g., TEFCA, QHIN, HIE, etc.).
 
Clearinghouse Responses:
• For payer customers, 43% plan to conduct the API data exchanges for them with 57% unsure, compared to the previous results of 62.5% and 31%, respectively. For provider customers, 57% plan to conduct the API data exchanges and 43% are unsure, compared to 69% and 25%, respectively.
• In estimating the current stage of completion with implementing the Patient Access API, 36% estimated they are 75% to 100% completed, up from 12%. Thirty-six percent are 25% or less complete, down from 73%. 
• In assisting payers and providers, 66% will assist them in complying with the API requirements, down from 84%.
• For the data metrics deadline on January 1, 2026, 47% are 75% to 100% ready for the reporting, up from 31%.
 
Vendor Responses:
•Sixty-seven percent plan to assist payers and providers in complying with the requirements, down from the previous result of 84%. 
 
“With a little more than a year before the 1.1.27 compliance date, it is concerning that 43% of payers and 47% of providers have not begun their implementation process. While these numbers are improved from our previous survey in January/February, they signal that significant work remains for the industry,” said Robert Tennant, WEDI executive director, in a statement. “The survey highlights the challenges of moving to new technology, modifying workflows, integrating data streams, and digitizing business policies. In the coming months, WEDI will continue to assess the readiness level of the industry to meet the regulatory requirements and work with impacted stakeholders to transition to exciting new interoperability solutions and much needed prior authorization automation,” Tennant added.
 
Additional survey results:
• When asked about implementing FHIR or both FHIR and X12 standards, 38% of payers plan to implement only the FHIR standard and 38% plan to implement both the FHIR and X12 standards, compared to 25% and 39%, respectively, from the previous survey. The percentage of “unsure” dropped from 33% to 23%. For clearinghouses, 57% plan to implement both the FHIR and X12 solutions, down from 81% previously.
• Most respondents (68%, up from 61%) were supportive of staggering implementation of the three prior authorization requirements: Coverage Requirements Discovery (CRD), Document Templates and Rules (DTR), and Prior Authorization Support (PAS), currently all required to be implemented on January 1, 2027. Forty percent favored starting with the CRD, followed by the DTR and then PAS as the staggered implementation approach.
• Most providers (56%) view having the majority of their payers supporting the prior authorization API requirements as extremely important, up from 41%.
• Forty-four percent of providers indicated they are somewhat or very likely to implement the Provider Access API, down from 72%. 
• All stakeholders identified that 1) Education on industry best practices; 2) Education on workflow design/modification; and 3) Advanced education (technical) on implementing APIs were the top educational resources needed for implementation of the CMS-0057-F requirements, which was the same result from the previous survey.