Payerbox for CMS-0057-F
CMS-0057 Compliance. Handled.
All four mandated FHIR APIs. Your data. Your rules. Our FHIR infrastructure.
Live before 2027
Zero disruption to existing systems
Da Vinci compliant out of the box
Full data ownership, any deployment
Trusted across the healthcare ecosystem
What CMS-0057 Requires
Four standardized FHIR APIs covering prior authorization, patient access, provider data sharing, and payer-to-payer exchange. Affects MA, Medicaid, CHIP, and QHP issuers. Full enforcement begins January 1, 2027.
FHIR Prior Auth for eligibility checks, needed documentation, and faster electronic decisions (7‑day standard, 72‑hour expedited).
Member‑facing FHIR APIs for claims, encounters, USCDI clinical data, and prior auth status, updated within 1 business day.
Bulk FHIR so in‑network providers can pull claims, clinical, and prior auth data for their patients with attribution and opt‑out.
FHIR data exchange when members switch plans — opt‑in, member match against the prior payer, and transfer of up to 5 years of claims, clinical, and prior auth history.
What You Get with Payerbox
No FHIR team required. Everything below ships pre-built. Your data never leaves your control.
Platform Capabilities
Da Vinci IGs, data connectors, security, consent, and member matching — pre‑configured for CMS‑0057. Deploy, don't build.
Patient Access, Prior Authorization, Provider Access, and Payer‑to‑Payer FHIR APIs pre‑built and aligned with CMS‑0057 guidance.
FHIR R4 data stored in PostgreSQL, queryable directly with SQL for analytics and downstream apps.
X12 278/275, C‑CDA, HL7v2, CSV, and custom adapters for bidirectional conversion to and from FHIR R4.
SMART on FHIR, OAuth 2.0, OIDC, and mTLS securing FHIR APIs and integrations end‑to‑end.
Configurable member portal and consent flows for Patient, Provider, and Payer‑to‑Payer APIs, with opt‑in/opt‑out and revocation management.
Immutable audit logs with decision timestamps, metrics, and consent events to support CMS reporting and internal audits.
Master data management to improve member matching across plans, data sources, and payer‑to‑payer exchanges.
FHIR terminology services for loading and validating against CMS‑aligned code systems (ICD‑10, CPT/HCPCS, RxNorm, LOINC, etc.) and the value sets referenced by Da Vinci and related IGs.
AWS, Azure, GCP, on‑prem, or hybrid — Kubernetes‑native, with managed and marketplace deployment options.
Implementation Timeline
A typical CMS-0057 deployment with Payerbox. Your existing systems stay untouched — Payerbox connects alongside them.
Map existing systems (claims, UM, clinical, eligibility) to FHIR resources. Define data flows, identify gaps, agree on deployment model.
Connect source systems via data connectors. Configure Da Vinci IGs, map source formats to FHIR R4, set up member matching and consent flows.
End-to-end API testing with Inferno and Touchstone. Conformance validation against Da Vinci profiles. Load testing and security review.
Production deployment, monitoring setup, CMS attestation support. Ongoing updates as Da Vinci IGs evolve.
Map existing systems (claims, UM, clinical, eligibility) to FHIR resources. Define data flows, identify gaps, agree on deployment model.
Connect source systems via data connectors. Configure Da Vinci IGs, map source formats to FHIR R4, set up member matching and consent flows.
End-to-end API testing with Inferno and Touchstone. Conformance validation against Da Vinci profiles. Load testing and security review.
Production deployment, monitoring setup, CMS attestation support. Ongoing updates as Da Vinci IGs evolve.
Compliance Data You Can Actually Use
Most compliance solutions are dead ends — FHIR data exists only to satisfy CMS auditors. With Payerbox, the same data is stored in PostgreSQL and exposed through standard APIs. Use it for analytics, applications, care management, AI — no additional ETL, no separate warehouse.
Member portals, internal tools, care management apps, third-party integrations — all powered by the same FHIR APIs and data store. No separate integration layer needed.
Conditions, encounters, and medications already structured per US Core. SQL on FHIR creates flat tables for HCC models and HEDIS measures directly on the compliance store.
Longitudinal FHIR records — including P2P history from prior plans — feed care coordination, utilization management, and population health programs without new ETL.
Structured FHIR data is ready for ML pipelines. Prior auth auto-decisioning, predictive models, NLP over clinical notes — all queryable via SQL or FHIR API.
Provider Access APIs generate attribution lists and data exports. The same infrastructure supports value-based care reporting and network analytics.
New Da Vinci IGs, dQMs, TEFCA-aligned exchanges — they land as configuration updates on the platform you already run, not as new projects.
In Production. Not in Pilot.
Real deployments with real payers. Not proofs of concept.
Patient Access API in production. Ranked #2 nationally in Flexpa’s 2025 Payer Patient Access API report (91/100). Built on Payerbox.
FHIR engine inside Innovaccer’s KLAS-rated data platform, used across 1,800+ hospitals.
Care management platform for self-insured employers. Production system serving hundreds of clients. Live in under a year.
CDR migration from FHIR STU3 to R4 in 4 weeks. 70% infrastructure reduction. SQL analytics directly on FHIR data.
AI-native risk adjustment on Aidbox. 70% reduction in RA spend. +1.0 RAF score per patient.
