Don’t Repeat These Patient Access API Mistakes: A CMS‑0057‑F Readiness Reset

Health plans invested heavily to meet the Patient Access API requirements under CMS‑9115‑F. APIs were built, documentation was published, and compliance boxes were checked. Yet for many organizations, those efforts produced little real‑world adoption.

The problem wasn’t technical failure, it was lack of activation. With minimal demand, Patient Access APIs were rarely used and never tested at scale. Gaps in onboarding, identity verification, data normalization, and workflow integration remained hidden, allowing APIs to exist on developer portals but not in practice.

The Centers for Medicare & Medicaid Interoperability and Prior Authorization Final Rule (CMS‑0057‑F) changes that dynamic. As operational demand increases, readiness gaps that once went unnoticed will surface quickly. Health plans now have a rare opportunity to pause before repeating the same mistakes. For CMS‑0057‑F investments to deliver more than compliance, leaders must take a clear‑eyed look at what worked, where adoption broke down, and what must change.

Before diving into the specific questions every organization should be asking, it helps to establish a shared baseline.

The CMS‑0057‑F Blueprint was created to help health plan leaders assess where they actually stand coming into this mandate. It offers a structured way to evaluate readiness across ownership, workflows, data, and connectivity so the lessons from CMS‑9115-F translate into better decisions this time around.

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CMS‑0057‑F Is Your Second Chance to Get it Right

Many health plans are taking steps to meet CMS‑0057‑F compliance, but before committing to new builds, vendors, or RFPs, it’s worth taking a deliberate pause.

The pause is not to re‑litigate every past decision, but to quickly and honestly assess where previous mandates broke down and whether the same patterns are quietly shaping decisions again. The questions below are intended to create shared clarity across teams and establish a stronger foundation for what comes next.

Are we taking the same approach that didn’t work under CMS‑9115-F?

Many organizations have based their CMS‑0057‑F efforts on the same assumptions that shaped the last mandate:

• “If we build the API, adoption will follow.”
• “The technical specifications define the strategy.”
• “Compliance ensures value.”

Experience shows otherwise. Technical conformance to Fast Healthcare Interoperability Resources (FHIR®) APIs and implementation guidance, without activation, produces endpoints that don’t meaningfully change workflows.

Are we stepping into the same pitfalls and how do we avoid them?

Common challenges that limited adoption under CMS‑9115 included:

• Fragmented, siloed efforts across IT, utilization management, analytics, provider relations, compliance, and procurement
• Vendor selection driven by technical spec scoring rather than long‑term strategy
• Underestimating the multi‑year nature of behavior change and adoption
• Writing RFPs before defining the strategic destination
• Delivering technology without a plan for activation or network readiness

If these patterns feel familiar, they’re worth addressing now before they quietly shape CMS‑0057‑F decisions.

What structural elements must be in place before moving forward?

To avoid rebuilding underused capabilities, organizations should ensure the foundations that were missing last time are clearly defined:

• Clear ownership of each API’s business purpose and success metrics
• An activation plan tied to incentives, contracts, or workflow modernization
• Governance that connects technical, operational, and network decisions
• A multi‑year adoption roadmap, not a one‑and‑done implementation

If any of these elements are unclear, the right move isn’t to stop progress, it’s to pause long enough to tighten alignment.

How can we measure value differently this time?

For CMS-9115-F success was measured by compliance, not impact.

With CMS‑0057‑F, success should be defined by outcomes that reflect operational and provider value, such as:

• Reduced administrative friction
• Decreased provider abrasion
• Increased electronic prior authorization throughput
• Expanded payer‑provider connectivity
• Improved clinical data completeness and quality
• Better member experience
• Cost efficiencies, such as reduced chart‑chase spending

These measures help ensure CMS‑0057‑F investments contribute to real business and operational outcomes, not just another set of unused APIs.

From Reflection to the CMS-0057-F Readiness Assessment

Taking time to pause and determine why CMS-9115-F didn’t give you value last time helps organizations understand why prior mandates didn’t deliver ROI. But reflection alone doesn’t guide execution.

The next, and often overlooked, step is answering a more practical question: Given what we’ve learned, where are we actually starting from with CMS‑0057‑F?

This is where many health plans lose momentum. Teams may agree that “things need to be different,” but lack a shared, objective way to translate lessons learned into decisions about sequencing, ownership, and investment.

Without that clarity, it’s easy to fall back into familiar patterns, issuing RFPs, selecting vendors, or building capabilities, before the organization is truly positioned to operationalize them.

In his discussions with health plan leaders across the industry, Chris Kenyon, Director of Clinical Solutions at Availity, consistently hears the same concern: the challenge isn’t whether organizations can build what CMS‑0057‑F requires. It’s whether they’re prepared to support, connect, and sustain those capabilities in real operational workflows.

APIs don’t fall short because they’re technically incorrect; they fall short when ownership, workflows, data readiness, and connectivity foundations aren’t in place.

That’s why readiness matters.

Download the Blueprint to access the readiness survey and learn how to translate your results into a practical, staged path forward before committing more time and resources.

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