CMS 0057 deadline is approaching: What Medicaid agencies need to know (and do now)

The federal government has made it clear: improving healthcare data interoperability and patient access is a national priority. CMS has introduced two major final rules—CMS-9115 and CMS-0057—designed to break down data silos, empower patients, and reduce delays caused by manual prior authorization. These mandates carry significant operational implications for Medicaid agencies, especially with compliance deadlines looming. But with the right technology, they also offer a chance to modernize outdated systems and streamline access to care.

That’s where Infor Cloverleaf comes in. Trusted by healthcare organizations and Medicaid agencies across the country, our clinical data interoperability platform goes beyond compliance—streamlining prior authorization with FHIR®-based data exchange and automation that reduces delays and improves outcomes. In the sections below, we’ll break down the requirements for CMS-0057 and show how Cloverleaf helps you meet them.

What is CMS-0057?

Finalized in 2024, CMS-0057 builds upon previous rulings and requires organizations to automate the prior authorization process and deliver faster, more transparent decisions. Certain provisions go into effect January 1, 2026.

These provisions impact Medicare Advantage organizations, Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the Federally-Facilitated Exchanges.

What does it mean for state Medicaid agencies

To comply with this rule Medicaid agencies must deliver the following under CMS-0057:

• Electronic Prior Authorization (ePA): Adopt FHIR APIs (CRD, DTR, PAS) to digitize workflows.
• Faster Decisions: 72 hours for expedited requests, 7 days for standard.
• Transparent Denials: Clearly communicate the reason for prior authorization denials (excluding drugs).

From mandates to meaningful change: simplifying prior authorization with Cloverleaf

For Medicaid agencies, these mandates go beyond technical compliance, they represent a vital opportunity to improve access to care for millions of patients, especially the most vulnerable ones. Prior authorization delays caused by manual processes and fragmented systems create significant barriers: care is delayed, providers face administrative overload, and payers battle high operational costs and member dissatisfaction.

To proactively address these challenges and fully comply with CMS-0057, Medicaid agencies need more than a basic integration tool. They need a flexible, standards-based solution built to operate seamlessly across both legacy and modern systems. Here’s how Infor Cloverleaf helps agencies meet these demands while transforming prior authorization workflows:

Modernize Medicaid prior authorization with a plug-and-play interoperability solution

State Medicaid systems often rely on legacy infrastructure that can’t keep pace with new FHIR API requirements. Our solution bridges that gap by working across all common data formats (HL7 v2, CDA, FHIR, X12) to translate, validate, and transmit prior authorization data seamlessly between providers and payers, without costly system overhauls. This plug-and-play approach accelerates your path to CMS compliance while reducing administrative burden.

Reduce administrative burden with embedded clinical intelligence

Our platform automatically extracts the right clinical data directly from providers’ EHRs and attaches it intelligently to prior authorization requests, tailored to payer-specific rules. This eliminates redundant manual work and back-and-forth with providers, ensuring more complete and timely submissions, helping your care teams get Medicaid beneficiaries the care they need faster.

Achieve CMS compliance and drive better health outcomes with end-to-end workflow orchestration

Meeting CMS mandates requires more than checking boxes. We support all four workflows—CRD, DTR, PAS, and CDex—and orchestrate the entire prior authorization lifecycle. Our solution provides real-time visibility into authorization status, comprehensive audit trails, and operational insights, empowering Medicaid agencies to maintain regulatory oversight, optimize workflows, and ultimately improve health outcomes for vulnerable populations.

The result? With Infor Cloverleaf, Medicaid agencies can automate the prior authorization process in full compliance with CMS-0057, saving time, reducing administrative burden, and helping patients get the care they need, faster.

Ready to get ahead of CMS deadlines?

Learn how Infor Cloverleaf can help your organization achieve compliance, streamline prior authorization, and deliver better care, faster.