Why a Network-First Approach Is Needed to Get ROI Out of Your CMS‑0057‑F Compliance Investment

Health plans have had ample time to absorb the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS‑0057‑F). The challenge now isn’t understanding the regulation; it’s figuring out how to execute it reliably and at scale across internal teams, external partners, and the provider and payer workflows that ultimately make or break adoption.

The friction many plans are feeling comes down to two realities:

1. CMS‑0057‑F cuts across multiple initiatives with different owners, priorities, and budgets, creating organizational drag, and
2. “Compliant” APIs alone don’t guarantee real data exchange. Without the surrounding infrastructure, provider/payer onboarding, identity and trust frameworks, monitoring, and workflow activation, data movement stalls long before it reaches its targeted workflows.

If these challenges feel eerily familiar, that’s because they are. Many health plans have experienced first-hand what happens when a mandate is treated as a technical exercise instead of an operational one. The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) is a recent example of how compliance can be achieved without any meaningful adoption.

In this blog, we’ll explore the underlying reasons why CMS‑9115-F never achieved real-world adoption, and outline the network‑first, cross‑functional approach to help ensure CMS‑0057‑F doesn’t meet the same fate.

What CMS-9115-F Was Trying to Solve and Why the APIs Stayed Dormant

When CMS‑9115-F introduced the first wave of payer APIs, the intent was to give members easier access to their health information and jump‑start a new era of data exchange across the industry. On paper, the rule established the technical building blocks for interoperability: standardized APIs, public directories, and a framework for sharing data more consistently.

But in practice, CMS‑9115-F delivered compliance without adoption. Health plans built the required endpoints, yet the data stayed doormat. Generally, providers didn’t change their workflows as a result of the mandate; members didn’t suddenly gain seamless access; and the broader ecosystem didn’t become more connected.

Why? Because CMS‑9115-F was treated as a technical exercise, not an operational transformation.

The industry assumed that if APIs existed, usage would naturally follow. Instead, CMS‑9115-F revealed several critical gaps:

• APIs were built but not connected to real workflows. The rule created endpoints, but not the onboarding, identity, trust, or routing infrastructure needed for actual exchange.
• Directories existed, but they didn’t lead anywhere. Without a functional “front door,” plans ended up with a map that pointed to endpoints few stakeholders could reliably access or use.
• Compliance overshadowed experience. Plans focused on meeting the letter of the rule, not on building the operational muscle needed to make data movement predictable, scalable, and valuable.

Teams were misaligned from the start. CMS‑9115-F sat across IT, clinical operations, analytics, and member services, yet no unified owner drove the full ecosystem required for adoption.

The result was a set of “compliant” APIs that checked the regulatory box but did not yield the industry-wide change the rule intended. In many ways, CMS‑9115 served as an expensive reminder that interoperability isn’t achieved by publishing endpoints; it’s achieved by enabling a network and putting mechanisms in place to consistently drive adoption and behavior change.

And unless plans shift their approach, CMS‑0057‑F is poised to repeat the same story.

What Interoperability Leaders Must Do Differently This Time

For VPs of Interoperability, the path to success calls for a shift from building endpoints to connecting to an ecosystem that makes those endpoints usable, reliable, and valuable.

Here’s what leaders must do to make that shift real:

1. Anchor Every Decision in the “Why”

This is a moment of strategic clarity for health plans. CMS‑0057‑F is not only about compliance; it is about:

• Boosting quality measurement and Star Ratings performance
• Improving provider/member experience
• Increasing data liquidity and enhancing clinical insights
• Reducing administrative waste
• Supporting more advanced value‑based care models

When leaders anchor the program in defined business objectives, decision‑making aligns more quickly and teams see the bigger picture.

2. Shift from API‑Building to Network‑Building

The single biggest learning from CMS‑9115-F is that APIs are only one component of interoperability. What matters is whether data can move end‑to‑end with predictability and trust.

To make that possible, leaders must intentionally invest in the infrastructure that sits around the API layer:

• Provider/Payer onboarding and provisioning
• Identity and trust frameworks
• Endpoint discovery and directory hygiene
• Monitoring, telemetry, and alerting
• Workflow activation inside provider systems

These capabilities are not “nice‑to‑have plumbing” they are interoperability.

3. Establish a Unified “Front Door” for Providers, Payers, and Trading Partners

One of the clearest failure points of CMS‑9115-F was that even when providers could find a plan’s endpoints, they often had no predictable way to access or use them. A “directory without a door” helps no one.

A unified front door solves this by providing:

• One place to find and authenticate
• One experience across CRD, DTR, PAS, and Payer‑to‑Payer
• One set of conventions, tokens, and trust relationships
• One support model and escalation path

This not only improves adoption, but it also dramatically reduces friction, rework, and operational overhead.

4. Align Ownership Across the Enterprise

CMS‑0057‑F spans IT, clinical operations, utilization management, analytics, compliance, provider networks, and member experience. When each of these groups owns a slice without shared governance, effort splinters and progress stalls.

Interoperability leaders must champion:

• Clear executive sponsorship
• A cross‑functional working group that meets regularly
• Shared KPIs and success metrics across teams
• A single narrative about what the organization is trying to achieve

This is not a compliance or an IT initiative. It is an enterprise initiative.

5. Treat CMS‑0057‑F as a Multi‑Year Upgrade to the Plan’s Operating Model

Interoperability doesn’t stabilize in a single release cycle. It matures through:

• Iterative improvements
• Continuous onboarding
• Evolving trust relationships
• Changes in provider/payer behavior
• Expansion into connected use cases

Leaders must plan for multi‑year investment in reliability, usability, and scale, not a one‑and‑done project that ends the moment compliance is achieved.

How the Availity® Network Activates FHIR-Based APIs

Without a network capable of securely routing normalized ready‑to‑use data at scale, health plans risk seeing CMS‑0057‑F turned into another CMS‑9115‑F, compliant APIs that no one uses, trusts, or connects to their day‑to‑day operations.

Availity changes that by operating the network CMS‑0057‑F assumes. For more than 25 years, we’ve provided the connective fabric the industry runs on:

• 98% of U.S. health plans connected
• 3.3 million healthcare providers
• $3T in billed claims processed annually
• Billions of clinical documents normalized
• The nation’s largest dual‑sided health information network

With Availity, health plans gain a partner that moves data across the ecosystem, normalizes information at scale, supports real-world provider usage all while enabling workflow modernization. That is the real promise of interoperability: activated data moving across a trusted, connected network.

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About the Author

Chris Kenyon is a mission-driven healthcare executive and sales leader at Availity, known for tackling complex business challenges and translating ambiguity into clear, market-ready product and commercial strategies. He brings deep experience across healthcare operations, economics, and both consumer and provider experience, with a strong track record of driving successful sales execution and value-based outcomes.