Why Plans Can’t Treat It Like a Checkbox Exercise

By Vincent Tumminello, AVP Solutions and Strategy, Abacus Insights

The Centers for Medicare & Medicaid Services’ proposed rule, Interoperability Standards and Prior Authorization for Drugs (CMS-0062-P) , marks a significant step forward in how interoperability is expected to work across the U.S. healthcare system.

At a high level, the rule extends the prior authorization interoperability framework beyond medical services to include drugs across pharmacy and medical benefits, while tightening timelines, standardizing denial reasons, and expanding reporting requirements. Taken together, its implications go well beyond electronic prior authorization.

This proposal pushes health plans toward a more transparent, API driven operating model. In that model, fragmented data, inconsistent workflows, and manual workarounds are harder to justify and harder to sustain under regulatory scrutiny.

For plans, the question is no longer whether to comply. It is how to prepare for a shift that touches utilization management, pharmacy, compliance, data governance, and both member and provider experience at the same time.

What CMS-0062-P Changes, and Why It Matters

CMS 0062 P builds on prior interoperability rules from 2020 and 2024, but with several important expansions.

Prior authorization interoperability now includes drugs
The proposal extends electronic prior authorization requirements to drugs covered under both medical and pharmacy benefits. This aligns expectations across Medicare Advantage, Medicaid, CHIP, and Qualified Health Plans, including small group QHPs on federally facilitated exchanges.

As a result, pharmacy workflows are now firmly part of the interoperability conversation. Many plans have historically treated these workflows as operationally distinct from medical services.

APIs move from supporting role to required infrastructure
The rule reinforces CMS’ commitment to FHIR based APIs. It proposes requirements to publish API endpoints, maintain updated technical documentation, and report on API usage.

Interoperability is no longer measured by whether an API exists. CMS is signaling an expectation that APIs are usable, discoverable, and actually used in practice.

Mandated FHIR Implementation Guides
Previous mandates allowed payers to store data in FHIR using resources as they saw fit, which created inconsistent behavior API to API, and payer to Payer. CMS-0062 pushes to require the industry-standard implementation guides (i.e. CARIN Blue Button STU 2.2 for Explanation of Benefits (claims).

This fundamental shift may necessitate a complete re-extraction of historical data to conform to the new required IGs. The end-goal is better interoperable data, and this is only the beginning of a journey to enforcing standards for interchange.

Transparency and accountability increase
The proposal includes more specific denial reason requirements and expanded public reporting of prior authorization metrics for drugs, beginning with data from the 2027 reporting period.

This increases visibility into how plans operate. Response times, denial patterns, and utilization controls become more visible to regulators, providers, and the public.

Why Compliance Alone Is Not the Real Challenge
Many organizations will understandably approach CMS 0062 P as a compliance milestone. They will focus on timelines, implementation guides, vendor readiness, and testing.
That framing, while necessary, is incomplete.

The rule assumes plans can access complete, timely, and usable data. It assumes decisioning is consistent across lines of business. It assumes that data exposed through APIs is accurate and meaningful. It also assumes plans can explain outcomes with confidence.

Those assumptions break down in environments where data is fragmented across platforms, vendors, and internal teams.
In practice, plans with weak data foundations will experience CMS 0062 P not as a one time implementation, but as ongoing operational strain.

How Plans Can Get Ahead of CMS-0062-P

Plans that are best positioned for CMS 0062 P are treating it as a signal to strengthen their interoperability backbone, not just their prior authorization workflows.

Three areas deserve early attention:

1. Unifying medical and pharmacy data
CMS-0062-P blurs the traditional boundary between medical and pharmacy benefits. Plans that still operate these domains on separate data islands will face complexity in decisioning, reporting, and transparency.

A shared, normalized data foundation supports more consistent workflows and more coherent reporting across benefits.

2. Preparing APIs for real world use
Publishing an API endpoint is not the same as operating an API at scale.

Plans need confidence that the data behind their APIs is complete, current, and reliable. They also need the ability to understand how APIs are being used and where gaps exist. API transparency requirements make interoperability a measurable capability.

3. Building confidence in outcomes
As reporting and denial reason requirements expand, plans need to trust the logic and data behind prior authorization decisions.

That means being able to explain not only that a requirement was met, but why an outcome occurred.

What to Do Now vs. What Comes Later

What to focus on now	What will come later
Assess whether medical and pharmacy data can be viewed and governed together	Final rule timelines and detailed implementation guidance
Understand how current APIs are supported by underlying data	Expanded reporting expectations and public visibility
Identify where reporting depends on manual or inconsistent processes	Ongoing refinement of interoperability standards and oversight mechanisms

Plans that separate foundational readiness from final compliance steps will be better positioned as details evolve.

Where Abacus Insights Fits

Abacus Insights approaches CMS-0062-P as a data and interoperability challenge, not a narrow prior authorization problem.
Our platform helps health plans unify clinical, claims, eligibility, and pharmacy data into a governed data foundation that supports interoperability at scale. That foundation enables plans to support APIs with trusted, reusable data rather than brittle point integrations. We already adhere to the industry standard implementation guides and stand ready to continue to support future releases via our data platform.

By sitting upstream of APIs, workflows, and analytics, Abacus gives plans flexibility as CMS requirements evolve. Requirements can change without forcing repeated re-architecture.

In a regulatory environment where interoperability expectations continue to expand, that flexibility matters.

Looking Ahead

CMS-0062-P is still a proposed rule. Timelines may shift and implementation details will continue to take shape.
The direction, however, is clear. Interoperability is no longer an abstract goal. It is becoming a monitored, measured expectation. Plans that rely on fragmented data strategies will find it increasingly difficult to keep pace.

Plans that invest now in strong data foundations will be better positioned to comply, operate effectively, and respond to what comes next with greater confidence.