The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) marked a significant shift for the healthcare industry, introducing new requirements for impacted payers to publicly report prior authorization performance metrics. For the first time, providers, patients, and regulators have access to standardized data that sheds light on how PA processes perform across plans.
Under the rule, impacted payers must publicly report:
- Average decision times (standard and expedited)
- Approval and denial rates
- A list of all medical items and services requiring prior authorization (excluding drugs)
- Volume of prior authorization requests
- Appeals outcomes
These disclosures represent an important step toward greater accountability. But beyond compliance, they also offer something arguably more valuable: a baseline for measuring and improving prior authorization performance across the industry.
Evaluating public prior authorization metrics
The introduction of public reporting naturally raises several key questions:
- Has transparency truly increased?
- Are payers achieving compliance with the requirements?
- Most importantly, how should industry stakeholders interpret these metrics moving forward?
While early observations suggest that many payers are meeting reporting requirements, the true value of these metrics lies in their role as a benchmark. They provide a snapshot of current-state prior authorization processes, capturing performance before the widespread deployment of modern interoperability solutions such as HL7 FHIR-based APIs mandated by the same rule.
In other words, the metrics reflect “today’s” prior authorization environment that is still heavily reliant on manual submission methods such as fax along with fragmented workflows. As digital transformation accelerates, these baseline measurements will serve as a critical comparison point to evaluate future improvements in efficiency, automation, and provider experience.
What public reporting reveals: Persistent administrative burden
One of the clearest insights emerging from public prior authorization data is the continued administrative burden across the healthcare ecosystem.
Prior authorization has long been a source of friction for providers, patients, and payers alike. While requirements such as responding to standard requests within seven calendar days are achievable for payers, the data underscores that compliance does not necessarily equate to efficiency.
A major contributing factor is the continued use of legacy submission methods, particularly fax. Despite regulatory and voluntary efforts to modernize prior authorization workflows, many requests are still submitted outside of digital interoperability frameworks.
This challenge is compounded by the fact that not all stakeholders are required to adopt the same standards. Delegated prior authorization vendors are not obligated to implement HL7 FHIR APIs and providers are not required to abandon legacy submission methods such as fax.
As a result, even after key regulatory deadlines (e.g., January 1, 2027), a significant portion of requests may bypass modern interoperability platforms entirely. This fragmented environment perpetuates inefficiencies, increases administrative costs, and limits the full realization of regulatory intent.
The path forward: Normalizing prior authorization through a single channel
To meaningfully reduce administrative burden, the industry must address the fragmentation of submission channels.
A practical and scalable solution is to consolidate all prior authorization requests, regardless of how they are submitted, into a single, normalized workflow. This approach involves:
- Accepting requests from multiple sources (fax, EDI, payer portals)
- Converting all submissions into a standardized HL7 FHIR format while extracting structured clinical data if possible
- Routing them through a unified interoperability platform
By normalizing data at the point of intake, health plans can streamline processing, enable automation, and ensure consistency across workflows. This not only reduces administrative overhead but also improves visibility into performance and outcomes.
Looking ahead: New reporting requirements on the horizon
The journey toward a more efficient prior authorization ecosystem is far from over. Pending CMS regulations under the proposed rule (CMS-0062-P) are expected to expand reporting requirements and provide additional insights into performance.>
Key proposed enhancements include:
Expanded prior authorization metrics
- Additional non-drug metrics with more detailed breakdowns
- Numeric counts and percentages to improve comparability
- New categories, such as the number and percentage of expedited requests approved after appeal
Drug prior authorization reporting
- Requirements to publicly report drug-related metrics
- Alignment with existing reporting structures for non-drug items and services
API usage metrics
CMS is also proposing new reporting requirements to track adoption and utilization of interoperability APIs, including:
Provider access API
- Number of unique providers accessing data
- Number of unique patients
- Total patient data transfers
Payer-to-payer API
- Patient opt-in percentage
- Number of unique patient records accessed
Prior authorization API
- Total provider requests
- Unique requests
- Percentage of requests submitted via API
These new metrics will provide a more complete picture of how effectively the industry is transitioning to digital, standards-based workflows and where gaps remain.
From baseline to transformation
The public reporting requirements introduced by CMS-0057-F represent more than a compliance exercise, they establish a foundation for long-term transformation.
Today’s metrics capture a landscape still shaped by manual processes and fragmented systems. Tomorrow’s metrics, particularly under proposed rules like CMS-0062-P, will begin to reflect the impact of interoperability, automation, and digital adoption.
For payers, the opportunity is clear: use current performance data as a baseline, invest in solutions that normalize and streamline workflows, and position the organization to meet evolving regulatory expectations while reducing administrative burden.
For the broader healthcare ecosystem, success will be measured not just in compliance, but in improved efficiency, better provider experiences, and ultimately, better outcomes for patients.
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This post is part of a series on prior authorization. Part 2 will explore the CMS-0062-P proposed rule in greater detail, including new reporting requirements for prior authorization and API usage.
