Interoperability in healthcare: How health plans can meet CMS and AHIP requirements

The first round of deadlines for the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is now in effect. Alongside payer-led initiatives such as the AHIP pledge, there is a renewed sense of urgency for health plans to achieve full interoperability. To meet compliance requirements and improve data integration, operational efficiency, and provider collaboration, plans must implement the right infrastructure—yet many face significant barriers. A recent WEDI survey found that digitizing prior authorization policies, meeting compliance timelines, and third-party vendor interoperability were the top challenges. 

Of course, these delays are nothing new. Health plans have historically struggled to meet interoperability requirements while ensuring optimal UM management. Traditional approaches to prior authorization policy management, for example, have been manual, complex, and resource-intensive—leading to compliance risks, administrative inefficiencies, and revenue leakage.

This year, health plans must rethink their approach to interoperability, move beyond compliance, and leverage new capabilities as a strategic advantage to fuel their future growth.

Moving toward full interoperability

Over the last few years, the healthcare industry has seen a greater push toward interoperability, driven by several key regulations. CMS-0057-F, announced in 2024, is intended to improve health information exchange among patients, providers, and health plans and enhance prior authorization processes. By January 1, 2026, health plans were required to implement certain operational provisions, and by 2027, public reporting is slated to begin. 

Then, in June 2025, AHIP, along with HHS and CMS, made parallel announcements about new industry-wide commitments to streamline and simplify the prior authorization process. The commitments include adopting FHIR^®-based APIs, making real-time decisions for at least 80% of requests using clinical documentation, reducing the scope of services subject to prior authorization, and improving communication and transparency around determinations, among others. 

These mandates, however, are only a starting point on the path toward interoperability, improvements in prior authorization, and regulatory compliance. Health plans must look to modernize their operations and improve accuracy, efficiency, provider collaboration, and the member experience, but they first need the right technological infrastructure and strategy in place.

Improving prior authorization policy management

As the WEDI survey found, medical policy digitization is a top priority for health plans as they seek to comply with CMS-0057-F. To ensure compliance with CMS and AHIP, support Documentation, Templates, and Rules (DTR) workflows and provide the policy context in Coverage Requirements Discovery (CRD) workflows, medical policies must first be digitized into an interoperable format. Digitization is also an essential step toward achieving transparency requirements.

While medical policies are the foundation for every prior authorization decision, for most health plans, these policies are contained in static PDFs, scattered Word documents, SharePoint folders, and disconnected web pages that must be manually converted into operational workflows. This process is fragmented, time-consuming, resource-intensive, and leaves health plans vulnerable to errors and compliance risks. Even for those who are using automation, relying on generic, off-the-shelf LLMs can lead to data drift. 

Additionally, without an intelligent policy infrastructure in place, health plans will continue to face a host of manual reviews, delayed review cycles, inconsistent decisions, and a lack of audit trails. Plus, without a digitized policy infrastructure, plans won't be able to achieve the 80% real-time approvals commitment in the AHIP pledge.

Ensuring interoperability compliance and future growth

Policy Studio, part of our enterprise platform, is a comprehensive solution that unifies policy creation, review, digitization, governance, deployment, and generates operational output. The solution creates digitized, structured proprietary policy assets that serve as the foundation for everything from UM decisioning to provider transparency, with full traceability back to the source policy, enabling health plans to maintain a single source of truth.

The solution enables: 

• Efficient, interoperable, FHIR-based prior authorization workflows
• Automated, structured policy digitization and codification
• Compliance with CMS-0057-F and AHIP interoperability commitments
• Automated, auditable, and transparent policy management
• Operational improvements while supporting provider trust and member care

By unifying policy management and automating workflows, health plans can reduce administrative burden, accelerate access to care, improve provider satisfaction, and transform policy management into a strength. Through Policy Studio™, on the Cohere Unify™ platform, our health plan partners operationalize compliance efficiently and defensibly, turning interoperability requirements into strategic advantages that improve long-term profitability.

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