Healthcare Has a Data Translation Problem
Across the conversations we’re having with health plans, states, and technology partners, one issue keeps coming up: healthcare data may be moving more freely, but that does not mean every system interprets it the same way. Data comes from EHRs, claims systems, labs, pharmacies, public health platforms, and other sources. Even when organizations use standards like […]
The CMS-0057 API Health Plans Are Already Using for Value-Based Care
CMS-0057 requires health plans to make claims, encounter, clinical, and prior authorization information available to providers through standardized APIs. But Provider Access does not have to be built for compliance alone. Health plans are already implementing the API in production to support value-based care contracts—extending the same interoperability foundation to give at-risk providers the information […]
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 […]
CMS-0057: Bringing Claims and Clinical Data Together to See the Full Member Story
Health plans have never lacked data. They’ve lacked a complete picture. Member history is often spread across providers, health plans, and disconnected systems, making it difficult to understand the full care journey when important decisions need to be made. CMS-0057 begins to change that. Through Patient Access, Provider Access, and Payer-to-Payer APIs, the rule creates […]
When Members Search for Their Doctor, Will Your Plan Show Up?
Provider directory accuracy has always been hard. But for Medicare Advantage plans, CMS-4208-F2 changes the stakes. Under the CMS-4208-F2 final rule, MA organizations must make provider directory data available to CMS/HHS for use in Medicare Plan Finder, update that information within 30 days of known changes, and attest at least annually that the data is […]
The API Works. The Network Is What Makes CMS-0057 Matter.
For health plans preparing for CMS-0057, standing up secure APIs is only one part of the work. The larger challenge is making those APIs exchange data with organizations outside the plan’s own environment — securely, reliably, and at scale. “The network becomes really powerful. It allows you to really move beyond, ‘I can get connected,’ […]
The Fax Machine Is Still Winning. Here’s How CMS-0057 Changes That.
Same payer. Two patients. Two completely different experiences. The first is on a Medicare Advantage plan — prior auth answered in seconds at the point of care, provider moves on with treatment. The next patient walks in on an employer plan with the same payer. Same provider. Same office. Different answer: send a fax. “The […]
From the Frontlines: CMS-0057 Is a Data Maturity Test
By Dinesh Y V, Implementation Manager, Onyx Electronic prior authorization requires more than APIs. As CMS-0057 moves from planning to execution, implementation teams are seeing where the real friction lives: fragmented payer data, inconsistent rules, and governance gaps that become visible in real-time workflows. The healthcare industry has spent years discussing interoperability, automation, and digital transformation. CMS-0057 is […]
CMS-0062: Why Drug Prior Authorization Is Only Part of the Story
If you’ve only skimmed the trade-press coverage of CMS-0062, you’d think the rule is about one thing: extending CMS-0057’s prior authorization framework to drugs covered under the medical benefit. That extension is real and it matters. It isn’t the story. The story is what CMS is doing around it. Assuming of course, that the rule is finalized in broad alignment with the proposed rule. CMS-0062 reaches deeper into payer […]
The Architecture Behind Intelligence: A Conversation with Dragon Bashyam
By Susheel Ladwa, CEO, Onyx Moving clinical data is no longer the hard part. Using it is. Payers today receive clinical information from dozens of sources — provider EHRs, public health systems, exchange partners — and most of it arrives fragmented, inconsistent, and hard to operationalize. Connectivity is solved. Intelligence isn’t. I wrote recently about […]