(Source: CMS)
8 Steps to an In-Network Rate and an Out-of-Network Allowed Amount Machine-Readable File1, 2, 3
Starting July 1, 2022,4 the Departments of Labor, Health and Human Services, and Treasury (the Departments) will begin enforcement of the requirement for non-grandfathered health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets to make available on an internet website machine-readable files providing information regarding: (1) in-network provider rates for covered items and services, and (2) out-of-network allowed amounts and billed charges for covered items and services.5 The machine-readable files must meet the requirements set forth in the Transparency in Coverage Final Rules that appeared in the November 12, 2020 edition of the Federal Register, referred to in this document as the “TiC Final Rules.”6 These Rules implement section 1311(e)(3) of the Patient Protection and Affordable Care Act (Pub. L. 111-148) and section 2715A of the Public Health Service Act. Technical implementation guidance for each of the machine-readable files is available through GitHub—an online collaborative hosting platform for development and source code management.
This document lays out 8 steps (Figure 1) to meeting the requirements for the In-Network Rate and the Out-of-Network Allowed Amount machine-readable files.
For both the In-Network Rate and Out-of-Network Allowed Amount machine-readable files, plans and issuers should start by identifying both the name and the plan identifier for each coverage option offered. The identifier must be one of the following:7
Once you have identified all coverage options (plans and products) offered, identify all items and services covered by those coverage options (except for prescription drugs that are subject to a fee-for-service reimbursement arrangement).8 “Covered items and services” means those items and services the costs for which are payable, in whole or in part, under the terms of a group health plan or health insurance coverage.9 “Items and services” are defined as all encounters, procedures, medical tests, supplies, prescription drugs, durable medical equipment, and fees (including facility fees), provided or assessed in connection with the provision of health care.10
Next, for each covered item and service, including each bundled payment arrangement,11 identify the billing code used by the plan (including the billing code type and version, if applicable) as well as a plain language description for each billing code. The TiC Final Rules require that plans and issuers associate each amount required to be reported with a billing code.12
The billing code is the code used by the plan or issuer to identify an item or service for the purposes of billing, adjudicating, and paying claims for a covered item or service.13 Plans and issuers may use a mixture of billing code types to identify covered items and services so long as the billing codes included in the files are consistent with the billing codes plans and issuers use in their operations for the purposes of billing, adjudicating, and paying claims.14
A "billing code" could include the CPT code, HCPCS code, DRG code, NDC (note that for prescription drugs, the billing code must be an NDC15), "or other common payer identifier."16 When a covered item or service does not have a corresponding code, a plan or issuer is permitted to choose its own indicator or other method to communicate to the public that there is no corresponding code.17
To facilitate identification of the billing code type, there is an indicator in the file schemas that allows plans and issuers to select the appropriate type of billing code for each item or service from a list of possible allowed values. The current list of possible allowed values for the billing code type is set forth in the table here. For billing code types that are not in this table, you may open a discussion on GitHub to suggest a new standard for the table. Information and updates regarding the inclusion of billing codes and billing code types in the file schemas can be found at this GitHub discussion on documenting different types of billing codes for negotiated rates.
Plans and issuers are also required to include a plain language description for each billing code reported. “Plain language” means written and presented in a manner calculated to be understood by the average participant, beneficiary, or enrollee.18 In the case of items and services that are associated with common billing codes (such as HCPCS codes), plans and issuers are permitted to use the codes’ associated short text description.
Once you have identified all covered items and services (Step 2) and related billing code information (Step 3), identify all applicable in-network rates and out-of-network allowed amounts and billed charges to be included in each file.
| In-Network Rate File | Out-of-Network Allowed Amount File |
|---|---|
| Plans and issuers must disclose all applicable rates19 for covered items and services provided by in-network providers.20 To do this, plans and issuers should start by gathering information from their provider contracts, rate sheets, or other files regarding their applicable rates with in-network providers for covered items and services (see discussion below regarding the types of applicable rates). | Plans and issuers must disclose unique out-of-network allowed amounts and associated billed charges for covered items or services furnished by out-of-network providers21 during the 90-day time period that begins 180 days prior to the publication date of the Allowed Amount file.22 To obtain these amounts, plans and issuers will need to access historical claims for items and services furnished by out-of-network providers during the period referenced above. |
| “Out-of-network allowed amount” means the maximum amount a plan or issuer will pay for a covered item or service furnished by an out-of-network provider.23 | |
| “Billed charge” means the total charges for an item or service billed to a plan or issuer by a provider.24 |
Next, for each amount specified above (that is, each in-network rate and each out-of-network allowed amount and billed charge), you will need to identify the relevant provider and location where the item or service was provided. To do this, each in-network rate and each out-of-network allowed amount and billed charge must be associated with the following three data elements:25