CMS-0057-F (Interoperability and Prior Authorization Final Rule)

CMS-0057-F is the CMS Interoperability and Prior Authorization Final Rule, published January 2024. It requires roughly 1,300 impacted payers (Medicare Advantage organizations, state Medicaid and CHIP fee-for-service and managed care programs, and QHP issuers on the federally-facilitated exchanges) to operate four FHIR R4 APIs by January 1, 2027: Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization. Prior authorization decision timeframes (72 hours expedited, 7 calendar days standard) and denial reasons take effect January 1, 2026.

Example

# Produce structural conformance evidence for an endpoint in CI.
# Exit 0 = pass. Exit 1 = a finding to read. Exit 2 = the walk validated nothing.

pidgeon data install fhir-us-core-6.0        # package id says 6.0; it installs US Core STU 6.1
pidgeon data install fhir-davinci-pas-2.1

pidgeon conform \
  --endpoint https://fhir.example.com \
  --walk --ci \
  --output-format html --output-file scorecard.html

pidgeon conform walks the endpoint's CapabilityStatement and validates one sampled instance per declared (resource, profile) pair. It produces structural conformance evidence against the published IGs; it does not judge semantic correctness, and no tool can settle a payer's regulatory obligations. A note on versions: the rule's required baseline names US Core 3.1.1 (45 CFR 170.215 as adopted), and US Core 6.1 is the ecosystem target most implementations build to. The Pidgeon package id is fhir-us-core-6.0 for historical reasons and installs US Core STU 6.1, and every scorecard stamps the exact IG version the run graded against. Without the installed package, validation falls back to an embedded subset and is flagged CONFORM_STUB_PROFILE.

Validation context

Strict and compatibility validation notes land here with the phase-1 data export.