CMS-0057-F final rule and CMS-0062-P proposed rule sandbox

The four CMS-0057-F payer APIs working end to end, extended to the proposed CMS-0062-P drug rule

This sandbox implements the four payer FHIR APIs that the CMS Interoperability and Prior Authorization final rule (CMS-0057-F) requires. CMS-0062-P, proposed on April 14, 2026, would extend prior authorization to drugs, make FHIR PAS a HIPAA standard, and add reporting, and the sandbox models those proposals too. The rule data comes from about 3,154 rules extracted from four publicly available 2026 BCBSIL prior authorization grids.

CMS-0057-F final
Final rule
CMS-0057-F
Regulation
45 CFR 156.221-156.223
API compliance date
January 1, 2027
Operational provisions
January 1, 2026
CMS-0062-P proposed
Status
Proposed, 91 FR 19890
Drug PA
October 1, 2027 (proposed)
Prior standard versions expire
January 1, 2028 (proposed)
FHIR PAS as HIPAA standard
24 months after the final rule (proposed)
Payer
UM Dashboard
Rules Explorer, Live Traffic Feed, Provider Access, P2P Exchange, proposed drug decision clocks, standards, and reporting.
Provider
EHR Workspace
Order entry → CDS Hooks card → DTR questionnaire → PAS Bundle, with proposed pharmacy and medical benefit drug PA tracks.
Member
Patient Portal
Coverage card, SMART scopes, and prior authorization history, including proposed drug PA resources.
Pharmacy
Pharmacy PA lookup
A sandbox addition where a dispensing pharmacy uses a SMART-scoped FHIR read to see the prescriber decision.
The four mandated APIs and where they live
156.223Prior Authorization API (CRD → DTR → PAS)/ehr + /um Live Traffic Feed
156.221(a)Patient Access API/patient
156.222(a)Provider Access API/um Provider Access tab
156.222(b)Payer-to-Payer API ($member-match)/um P2P Exchange tab
45 CFR sections shown are for QHP issuers. Parallel sections: MA 42 CFR 422.119, 422.121, 422.122 · Medicaid 42 CFR 431.60, 431.61, 431.80 · CHIP 42 CFR 457.730, 457.731, 457.732.
What CMS-0062-P adds, and where it lives
45 CFR 170.205(b)(2), (c)(1), (u)(1)
Proposed drug PA on the pharmacy benefit over NCPDP SCRIPT ePA, with RTPB and F&B.
/ehr: self-administered certolizumab order
Proposed CMS-0062-P
Drug PA on the medical benefit through CRD, DTR and PAS.
/ehr: clinic-administered certolizumab order
My position
One question set, one decision and one coded denial reason across both drug tracks.
/ehr: clinic-administered certolizumab order
SSA 1927(d)(5), proposed 45 CFR 156.223(i)(1)(ii), 42 CFR 422.568, 422.572
Decision clocks by program, with a citation on each decision. Medicaid has a 24-hour covered outpatient drug clock and a 72-hour emergency supply. Proposed QHP drug clocks are 24 hours expedited and 72 hours standard. MA Part B drug decisions use 42 CFR 422.568 and 422.572. Commercial employer plans have no federal clock.
/ehr decision badges and /um Live Traffic Feed
Proposed 45 CFR 156.221(b)(1)(v)
Proposed drug PAs in Patient Access, Provider Access, and Payer-to-Payer as PDex Prior Authorization ExplanationOfBenefit resources, with parallel MA, Medicaid, and CHIP sections.
/patient, /um Provider Access, and /um P2P Exchange
Sandbox addition
A pharmacy PA lookup lets a dispensing pharmacy read the same decision as the prescriber over a SMART-scoped FHIR read. This is not a rule requirement.
/pharmacy
Proposed 45 CFR 170.215
Versioned standards from one registry, with the proposed versions and their sunset dates. Patient Access uses US Core 6.1.0 because US Core 3.1.1 expired from 170.215 on January 1, 2026.
/um Standards tab
Proposed CMS-0062-P
An endpoint report of FHIR Endpoint resources, API usage reporting, and PA metrics as counts and percentages.
/um Registry & Metrics tab
My position
Third-party connection success and error rates.
/um Registry & Metrics tab
Proposed 45 CFR 162.1302(g)(2)(vii)
CDex attachments on pended requests.
/ehr: pended 15820 order and the DTR pane clearinghouse toggle
Sandbox addition
A clearinghouse gate that rejects a nonconforming PAS Bundle before it reaches the payer.
/ehr: pended 15820 order and the DTR pane clearinghouse toggle
CMS-0062-P is proposed. Citations follow the proposed text and may change in the final rule. Read the plan and positions document.
A suggested path through the demo

The sandbox boots pre-seeded with the full rule index and a replayed demo session, so every surface has data before the first click. The steps below walk one order through all four APIs.

  1. 1/umOpen the UM dashboard. The rule index is pre-loaded. Search 70553 in the Rules Explorer to see the MRI Brain rule, its routing, and its provenance back to the source PDF page.
  2. 2/ehrOpen the EHR as Jane Doe and sign the MRI Brain order. A CDS Hooks card returns with the DTR questionnaire link. Complete it and submit the PAS request.
  3. 3/umBack in the UM dashboard, watch the Live Traffic Feed. Expand the FHIR ↔ X12 drawer on the X12 278 REQUEST entry to inspect the field-to-segment mapping.
  4. 4/patientOpen the patient portal as Jane Doe. The same determination appears in her prior authorization history through the Patient Access API.
  5. 5/umIn the P2P Exchange tab, run $member-match for a newly enrolled member and retrieve the prior plan PA history.
The CMS-0062-P additions
  1. 1/ehrPick a certolizumab order, self-administered or clinic-administered, and leave the step therapy box unchecked. Run the other order to see the answers carry over and both tracks deny with the same reason.
  2. 2/ehrSelect Maria Santos for Medicaid or David Kim for QHP, then sign the default order to see the decision clock for that program.
  3. 3/pharmacyLook up Jane Doe and the certolizumab NDC.
  4. 4/umOpen the Standards and Registry & Metrics tabs.
Source on GitHub · AGPL-3.0 licensed. The source for this deployment is the repository linked above.
CMS-0062-P plan and positions document
Demonstration environment with synthetic patients. The rule data comes from publicly available BCBSIL documents (Medicare Advantage, Commercial Med-Surg, Specialty Pharmacy, Behavioral Health). This project is not affiliated with or endorsed by BCBSIL, CMS, Epic, Availity, Optum, or Prime Therapeutics.
Data use. This sandbox processes only synthetic patient data by default. When launched from an external EHR sandbox via SMART on FHIR, the launched Patient resource is fetched and displayed for the current browser session only. Nothing is persisted, sold, shared, or used for any secondary purpose. Access tokens live in sessionStorage and clear on tab close or when the "End session" control is used.
The Reset demo control in the UM dashboard restores the seeded baseline at any time.