Onyx Blog
CMS-0057 and CRD: Giving Providers Answers Before the Patient Leaves
A prior authorization answer delivered while the patient is still in the office can create a very different care experience than one that arrives days later.
Without real-time information, a provider may have to send the patient home, confirm requirements with the health plan, reconnect by phone, and schedule another appointment.
That delay is not just administrative. It can interrupt the next step in care.
CMS-0057 creates an opportunity to change that.
The rule establishes a stronger foundation for data exchange across Patient Access, Provider Access, Payer-to-Payer, and electronic prior authorization workflows. In the latest video in our series with Availity, Mark Scrimshire, Chief Interoperability Officer at Onyx, explains why Coverage Requirements Discovery, or CRD, may be one of the most immediate ways health plans can turn that foundation into a better provider and patient experience.
“If you can give an answer to the provider in real time to say, ‘You don’t need a prior auth,’ they can fundamentally change the way the patient is treated.”
Mark Scrimshire, speaking with Availity
CRD is designed to give providers information about coverage and prior authorization requirements within their workflow.
That matters because one of the most useful prior authorization outcomes is also one of the simplest:
No prior authorization is required.
When that answer is available in real time, the provider does not need to let the patient leave while staff confirm requirements, make follow-up calls, or arrange another visit.
Instead, the conversation can move directly to the next step:
“Let’s schedule you for next Wednesday.”
That is a practical example of what CMS-0057 can make possible when standardized APIs are connected to real clinical and administrative workflows.
Mark also points to Payer-to-Payer exchange as part of the broader foundation.
As member data moves between health plans, organizations can gain access to more of the information needed to support continuity across coverage transitions.
That stronger data foundation can then support additional workflows, including electronic prior authorization.
The value is not in building each API as a separate compliance project.
It is in creating an exchange foundation that can be reused across multiple interactions among payers, providers, and members.
Prior authorization has traditionally depended on manual checks, portals, calls, faxes, and follow-up work that happens after the patient encounter.
CRD moves an important part of that process closer to the point of care.
When the provider can receive coverage guidance within the workflow, the organization can:
This is where CMS-0057 begins to create value that patients and providers can actually experience.
The API is not the outcome.
The outcome is a faster, clearer decision while there is still an opportunity to act on it.
Standing up CRD, DTR, and PAS endpoints is essential, but technical compliance alone will not deliver this experience.
Health plans also need accurate and computable coverage rules, consistent benefit information, reliable provider and member data, and workflows that can return useful answers in real time.
If the underlying policies remain trapped in PDFs, spreadsheets, or inconsistent internal systems, the API may technically function without giving the provider the clarity needed to move care forward.
The organizations that realize the greatest value will be the ones that connect the technical implementation to the operational question:
Can the provider get a reliable answer while the patient is still there?
That is the standard that matters.
Onyx helps health plans build the data foundation that powers continuous compliance—so every new CMS mandate strengthens rather than strains operations.
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