Payer Integration Solutions for CMS-0057-F & X12 EDI
PilotFish automates the exchange and validation of healthcare X12 EDI, including 278 prior authorization, 837 claims and 835 remittance. PilotFish helps impacted payers adopt FHIR APIs and meet CMS-0057-F timelines, with operational changes effective January 1, 2026 and FHIR API requirements by January 1, 2027, including Provider Access, Patient Access, Payer-to-Payer and Prior Authorization APIs.
Supported formats: X12, HL7, FHIR, XML, JSON, CSV, DICOM and flat files.
Audit: Built-in auditing and reporting support CMS mandates.
CMS-0057-F readiness: Implement FHIR APIs, integrate legacy X12 such as EDI 278, improve prior auth transparency to meet 2026–2027 timelines.
Healthcare Payer Prior Authorization & Claims Flow
PilotFish for X12 EDI & CMS-0057-F
PilotFish streamlines exchange of high-quality data across payers, providers and government programs. PilotFish’s robust, modern and flexible platform enables leveraging EDI, HL7, FHIR, XML standards, web services and Application Server Technology.
Virtually any standard can be supported using the identical low-code, no-code automated PilotFish graphical configuration process. Our native XML support ensures you can handle any future healthcare standard.
- Data Transformation: PilotFish’s eiConsole for X12 accepts information in any format – Excel spreadsheets, PDFs, Word documents, email attachments, JSON, flat files and CSV. Out-of-the-box support for all standards – X12 EDI, HL 7, FHIR, XML, CCD/CCDA, DICOM.
- Validation: PilotFish’s EDI validation processor checks for errors and inconsistencies before data exchange. Support for SNIP Types 1-7 tests every EDI transaction sent or received to ensure compliance with trading partner and CMS requirements.
- Built-In X12 Access: As a licensed select distribution partner of X12, PilotFish’s built-in access to X12 standards artifacts lets users rapidly parse, validate and produce X12 standard messages without needing to manage the complexities of the standard separately. (The eiConsole for X12 EDI supports 5010 HIPAA, 7030 HIPAA, 4010 HIPAA and non-HIPAA EDI.)
- Clean Data: PilotFish delivers clean, validated and integrated data for analytics, automation and AI.
- No Vendor Lock-In: PilotFish easily integrates with any EMR/EHR, analytics platforms, data lakes and partner systems via standards-based adapters and transformers, avoiding vendor lock-in.
How PilotFish’s FHIR Platform Helps Payers Meet CMS-0057-F Compliance Deadlines
CMS-0057-F mandates decision timeframes, denial-reason transparency and public metrics in 2026, plus FHIR-based APIs in 2027.
- FHIR Transformation Support: PilotFish can ingest data from legacy systems (e.g., X12, HL7 v2, flat files) and convert it into FHIR-compliant resources.
- API Enablement: PilotFish can wrap transformed data in a FHIR RESTful API that is standards-compliant and accessible to patients or third-party apps.
- Security Integration: With PilotFish, OAuth2 and SMART on FHIR support can be integrated into the flow for secure data access.
PilotFish supports payer applications across healthcare and all aspects of Medicare and Medicaid reporting and CMS compliance, including the generation of:
- 837 Claim Files: detailed information about patient, diagnosis, treatment and charges for the services provided. Used to submit claims for reimbursement to Medicare and Medicaid.
- 835 Remittance Advice: payment information and details about any adjustments or denials of claims.
- 278 Prior Authorization: approval for treatments, services, or specialty referrals before they are provided. (CMS-0057-F mandates apply to prior authorization electronic and real-time data exchange and generation of FHIR APIs.)
- CMS-1500: Claim-1500 – standard claim form used by healthcare providers to bill for services provided to Medicare and Medicaid beneficiaries.
- 270/271 Eligibility Verification: checks a patient’s eligibility for benefits and coverage.
- 276/277 Claim Status: checks the status of claims submitted – date of payment, amount of payment, any denials or adjustments.
- Encounter Data: Used to submit claims for reimbursement under capitation payment models. Encounter Data contains detailed information about patient, diagnosis, treatment and charges for the services provided.
- 823 Electronic Funds Transfer (EFT) and 824 Electronic Remittance Advice (ERA): EDI 823 for EFT allows for the electronic transfer of funds and EDI 824 for ERA remittance advice for claims.
- Electronic Prescribing of Controlled Substances (EPCS): PilotFish supports EDI transactions, such as the NCPDP Telecommunication Standard for EPCS, which allow for the electronic prescribing of controlled substances.
- FHIR APIS: FHIR-based APIs for Patient Access, Provider Access, Payer-to-Payer Data Exchange and Prior Authorizations, plus X12 ↔ HL7 FHIR Mapping.
PilotFish: Smartest Payer Integration Strategy in Cost, Resource Use and Speed
At PilotFish, our sole focus has been on integration for over two decades. PilotFish has a long, successful history in the health insurance industry. The ACORD standards organization (the HL7.org of the insurance industry) is a long-time licensee of PilotFish products. In fact, PilotFish’s software is utilized by 90% of the top health insurers and leading payers.
Explore our Case Studies. See how PilotFish delivers the fastest and most efficient way to integrate and exchange data and reports with trading partners, other payers and CMS.
Contact us to review your interface requirements or request a walk-through. Download a complete, FREE 90-Day Trial Version of our software and get a real sense of the ease-of-use of PilotFish’s Interface Engine solutions in just 20 minutes.
FAQ
CMS-0057-F is a CMS interoperability and prior authorization rule that requires payers to provide faster decision-making timeframes, greater transparency in denial reasons and publish prior authorization metrics by January 1, 2026. By January 1, 2027, payers must also implement FHIR-based APIs for Provider Access, Patient Access, Payer-to-Payer and Prior Authorization data exchange.
PilotFish enables payers to integrate legacy X12 EDI transactions with new FHIR APIs. The platform automates data transformation, validation and API enablement, ensuring compliance with CMS-0057-F timelines for prior authorization transparency and FHIR API implementation.
PilotFish supports all primary healthcare EDI transactions, including:
- 837 claim submission
- 835 remittance advice
- 278 prior authorization
- 270/271 eligibility verification
- 276/277 claim status
- 823/824 EFT and ERA
- CMS-1500 claims and encounter data reporting
Yes. PilotFish ingests data from X12 EDI, HL7 v2, flat files, Excel, PDFs, JSON and XML, then converts them into FHIR-compliant resources. These can be exposed through RESTful APIs, enabling interoperability between legacy systems and modern FHIR applications.
PilotFish includes built-in validation processors that verify data integrity before exchange. The platform also supports SNIP Levels 1–7 testing, ensuring that every transaction meets both CMS and trading partner requirements.
Yes. As a licensed select distribution partner of X12, PilotFish offers built-in access to official X12 standards artifacts. This allows users to rapidly parse, validate and generate compliant X12 messages (including 5010 HIPAA, 7030 HIPAA, 4010 HIPAA and non-HIPAA EDI) without needing to manage the complexities of the standard themselves.
PilotFish integrates OAuth2 and SMART on FHIR protocols directly into data flows. This ensures that patient and provider data shared via FHIR APIs is fully secure and meets CMS interoperability requirements.
Related Case Studies
Explore how other leading healthcare payers and insurers have used PilotFish to achieve seamless integration, CMS compliance and automation.
- Claims Processing Integration Case Study
A significant health insurer streamlined the claims intake, transformation and exchange of EDI 837 and 835 transactions, resulting in reduced processing times and errors. - Medicaid Encounter Data Processing Case Study
PilotFish enabled automated submission of encounter data to Medicaid, improving compliance, accuracy and reporting efficiency. - Healthcare Insurance Integration Case Study
A national payer utilized PilotFish to integrate X12, HL7 and proprietary formats, ensuring interoperability and compliance with CMS reporting requirements.
Explore additional healthcare integration case studies.
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HL7 is the registered trademark of Health Level Seven International.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.