PilotFish FHIR Platform Helps Payers Meet CMS-0057-F Compliance Deadlines

PilotFish Helps Payers Rapidly Adopt HL7 FHIR APIS and Comply with CMS-0057-F

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) marks a transformative shift in how payers must manage and share healthcare data. CMS-0057-F is complex with technical requirements that force integration between outdated legacy systems and modern HL7 FHIR APIs.

PilotFish’s Integration Platform for healthcare (eiPlatform) is exceptionally well-positioned to help payers comply with the 2026-2027 CMS FHIR mandates and tight timelines requiring:

• Rapid adoption and implementation of FHIR APIs
• Seamless integration of legacy formats like X12 278
• Enhanced transparency in Prior Authorization workflows

How PilotFish’s FHIR Built-In Capabilities Help You Meet CMS-0057-F Mandates

1. Decision Timeframe Reporting – Required by Jan 1, 2026

Payers must provide specific denial reasons for prior authorizations and track timing metrics.

How PilotFish Can Help:

• Custom Reporting: PilotFish’s eiDashboard can generate required reports on turnaround time and reasons for denial through easy configuration of reporting flows.

2. Patient Access API (including Prior Authorization Data) – Required by Jan 1, 2027

Payers must make USCDI and prior authorization data available to patients via a FHIR-based Patient Access API.

How PilotFish Can Help:

• FHIR Transformation Support: PilotFish can ingest data from legacy systems (X12, HL7 v2, flat files, etc.) 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.

3. Provider Access API – Required by Jan 1, 2027

Payers must make claims, encounter, USCDI and prior authorization data available to in-network providers with treatment relationships.

How PilotFish Can Help:

• Data Orchestration: PilotFish can easily route and aggregate data from multiple internal systems and transform it to FHIR data format.
• Real-time API Delivery: Serve provider queries via a FHIR API, leveraging PilotFish’s support for RESTful interfaces and data enrichment.
• Opt-Out Workflow: PilotFish can orchestrate workflows to manage patient consent/opt-out rules, integrating them into API responses.

4. Payer-to-Payer API – Required by Jan 1, 2027

Payers must enable FHIR-based data exchange between payers when a patient switches plans.

How PilotFish Can Help:

• Payer Integration Framework: PilotFish can facilitate FHIR-based push/pull exchanges with other payers.
• Consent & Education Integration: PilotFish can incorporate logic to check opt-in status and trigger delivery of educational content or confirmation.

5. Prior Authorization API – Required by Jan 1, 2027

Payers must support fully electronic prior authorization processes, including status updates and required documentation.

How PilotFish Can Help:

• X12 ↔ HL7 FHIR Mapping: PilotFish’s Graphical Assembly Line process translates X12 278 prior authorization requests and responses to FHIR resources and vice versa, meeting CMS-0057-F’s technical expectations.
• Workflow Automation: PilotFish’s eiConsole IDE for healthcare can automatically route prior authorization requests to the right department, apply business rules, and generate FHIR-compliant responses.
• Decision Support Integration: PilotFish can integrate with external systems (like UM tools) to fetch documentation rules or automate decisions.

FHIR to X12 278 Prior Auth Workflow using PilotFish

How PilotFish’s FHIR Integration Delivers Game-Changing Benefits for Payers

PilotFish streamlines the entire lifecycle of FHIR implementation, from transformation to monitoring. PilotFish enables organizations to achieve far greater efficiencies and lower costs with:

• Legacy System Compatibility: PilotFish bridges the gap between legacy data formats and modern APIs without requiring the replacement of existing infrastructure.
• Rapid Integration: PilotFish FHIR components accelerate time to compliance. Achieve workflow automation for Prior Authorization and more.
• Vendor Neutrality: PilotFish can integrate with any EMR/EHR, analytics tool, or partner system, giving payers unmatched interoperability, flexibility and control.

Why Not Leverage CMS-0057-F Compliance as a Major Payer Opportunity?

For leading payers, CMS-0057-F compliance is about more than just meeting regulatory obligations. It’s a major opportunity with PilotFish as your partner to:

• Modernize systems
• Reduce administrative burden
• Deliver better experiences for patients and providers alike.

With PilotFish, you’ll navigate CMS compliance complexity with confidence, beat CMS FHIR compliance deadlines, plus leverage CMS mandates to move ahead with FHIR interoperability.

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.