5 key takeaways: End-to-end traceability and automation for CMS-0057-F

CMS-0057-F marks a major milestone in modernizing prior authorization, but meeting regulatory requirements alone doesn’t guarantee efficient, accurate, or provider-friendly workflows. FHIR APIs enable data exchange, and many health plans now have strategies in place for the APIs required under CMS-0057-F, but APIs are just the roads. Without digitized, executable policies to guide decisions, there’s no way to safely automate how traffic moves across them.

Findings from the WEDI 2025 Interoperability & Prior Authorization Survey reinforce the urgency. Digitizing prior authorization policies ranks among the top challenges, alongside workflow redesign and enterprise strategy alignment, while internal readiness remains a significant gap. 

In our recent webinar, Cohere Health explored how policy digitization, AI-driven data extraction, and clinically intelligent automation help plans move beyond baseline compliance and turn regulatory success into operational excellence.

Below are five key takeaways from the discussion: 

“APIs alone aren’t enough. Policy is the missing foundation for making interoperability drive real value across payer and provider interactions.”  — Matt Parker, Chief Product Officer, Cohere Health

1. APIs create access—not clarity

FHIR APIs and Documentation Templates and Rules (DTR) requirements establish the foundation for real-time data exchange, but they don’t define documentation expectations or explain how clinical decisions are made. Without policy intelligence behind the API, health plans continue to rely on manual reviews, experience inconsistent outcomes, and create provider frustration. 

Plans that see the most value from API investments treat connectivity as the starting point—pairing FHIR-based workflows with policy-aware automation so evidence requirements and decision logic are driven by policy, not manual interpretation.

2. The real compliance gap is traceability

Many health plans still struggle to answer fundamental questions: 

• Why was a case approved or denied?
• Which policy version was applied? 
• Does the policy match what is executed in ePA workflows?
• Where does the audit trail live? 

In many cases, the challenge isn’t the absence of clinical data, but the way policies are managed and executed across workflows. When policy is digitized and centrally managed, every decision can be traced back to the exact criteria applied, the evidence evaluated, and the policy version in effect. 

3. You can’t automate what you haven’t digitized

CMS’s goal—and AHIP’s commitment—to reach 80% real-time approvals cannot be achieved safely or consistently through manual policy interpretation. PDFs and fragmented guideline sources lead to variability, review backlogs, and operational risk.

Plans that successfully scale automation invest in a centralized, digital policy foundation designed for governance, version control, and reuse. In this model, policies are authored once and executed consistently across workflows, transparency portals, and audits—turning policy into infrastructure rather than documentation.

4. Clinical AI works best when policy is the executor

Many health plans that have implemented FHIR-based prior authorization APIs and adopted the HL7 Da Vinci implementation guides have effectively built the compliance “highway.”

However, because CMS requirements for policy documentation are less prescriptive, policies are often converted into clinical questionnaires surfaced to providers. In practice, this approach introduces risk. Cohere Health has observed inaccurate responses in more than 30% of questionnaire-based workflows, often because administrative staff are asked to attest to clinical criteria.

Most of the clinical evidence required for medical necessity determination already exists in unstructured clinical notes, which are more complete and accurate than questionnaire-based responses. When AI is used to extract and evaluate that evidence directly against policy criteria, plans can improve accuracy, reduce provider burden, and enable safer, more scalable automation. 

5. Policy infrastructure enables both compliance and innovation

When policy becomes a single source of truth, health plans unlock more than regulatory compliance. They gain the ability to scale real-time approvals, apply consistent logic from initial decisions through appeals, expose transparent criteria to providers, and continuously optimize policy execution.

Rather than viewing CMS-0057-F as the finish line, leading organizations treat it as a foundation that enables faster, safer, and more transparent prior authorization experiences as automation matures.

How policy infrastructure comes to life in practice

Throughout the webinar, one message was clear: APIs alone won’t deliver meaningful improvement without policy and workflow transformation. This is the challenge we designed Cohere Policy Studio™ to address.

Policy Studio enables health plans to digitize, manage, and govern medical necessity policies in a centralized system—then automatically distribute those policies across authorization workflows, transparency portals, and audit trails. Policies are versioned, traceable, and built for automation, ensuring consistent execution from real-time decisioning through appeals.

Want the full roadmap? 

This blog captures only a portion of the discussion from our WEDI webinar, Policy in action: End-to-end traceability and automation for CMS-0057-F. Whether your organization is just starting its CMS-0057-F compliance journey or already live on FHIR APIs, the webinar provides a framework for turning regulatory requirements into sustainable operational improvements.

Watch the webinar on demand here.