Transparency in Coverage Rule: Machine Readable Files
In 2020, the “Departments” (HHS, DOL, Treasury) within the Federal Government finalized the Transparency in Coverage rule. This legislation was instituted with the intention of improving the affordability and transparency of healthcare.
A key provision within this rule requires health insurers and plans to publish two separate machine-readable files by July 1, 2022.
- In-Network Negotiated Rates: All rates for covered items and services that have been negotiated between a plan/issuer and their in-network providers.
- Out-of-Network allowed Rates: A historical allowed amount in claims paid (more than 20) and the billed charges from out-of-network providers over the previous 90 days
Guam/CNMI/Palau
In Network - Pending
Out of Network - Pending
Hawaii/CONUS
In Network
Out of Network
DISCLAIMER
- Transparency in Coverage final rules require health plans and health insurance issuers to disclose in-network negotiated rates and out-of-network billed charges/historical allowed amounts through two machine-readable files posted on an internet website.
- A machine-readable file is defined as a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention, while ensuring no semantic meaning is lost.
- The machine-readable files above are published to comply with federal regulations. They are in the Centers for Medicare & Medicaid Services (CMS) defined format (JSON) and are not meant for a member-friendly search of rates, benefits, or cost sharing. A member-friendly cost comparison tool is planned to be introduced in Q3 2023.
- Not all services and procedures listed are offered by providers. Available services may change from time to time.
- The base rates reflected are unadjusted for the participants, beneficiaries, or for enrollee-specific factors. Provider rates are subject to change throughout the year which will be reflected in the next file update.
- Though these files may provide information on the cost of a specific service item, the actual payment for a related patient claim may be different and may be affected by a variety of factors including, but not limited to, the mix of items, the use of modifiers, eligibility/benefit determinations and other negotiated payment methodologies.
- If there is a discrepancy between a negotiated rate listed in the machine-readable file(s) and the contracted rate applicable to a specific patient claim, the terms of the provider contract will prevail.
