The federal Transparency in Coverage final rule, jointly issued in October 2020 by the Department of Health and Human Services (HHS), the Department of Labor and the Department of the Treasury, contains many requirements that have implications for health insurers, health plans, healthcare providers and consumers.
One provision in the Transparency of Cost Rule requires nongrandfathered group health plans and health insurance issuers in the individual and group health markets to disclose certain pricing information in publicly available machine-readable files posted to a website.
These files must contain:
- In-network negotiated rates with healthcare providers
- Historical payments to out-of-network healthcare providers (including out-of-network healthcare providers’ billed charges)
Table of contents file (json)
To submit questions or technical support requests related to machine-readable files, please email firstname.lastname@example.org.
- Pricing included in data contained in posted machine-readable files is accurate as of the date it is extracted but may change before the next update of the files. The pricing data in posted machine-readable files is not a guarantee of payment and may not always match amounts that appear on final documentation after claims are fully processed. The pricing data in posted machine-readable files also is not an estimate of the costs members will be responsible for paying for such items and services. Individual costs will vary, depending on the terms of the member’s specific health insurance coverage and the structure of the reimbursement arrangement, if applicable. Benefits and eligibility are determined when the claim is processed by Arkansas Blue Cross and Blue Shield or its affiliates.
- Rates for codes in posted machine-readable files may vary when a modifier is applied or when rate adjustments result from certain member benefit or treatment characteristics. The presence of differing rates for identical codes may indicate that a modifier or some other type of member benefit or treatment characteristic was applied.
- The format requirements for machine-readable files may result in very large file sizes. Accordingly, to prevent problems when downloading machine-readable files, please ensure that your internet connection is stable and robust enough to handle large downloads. Also, if you encounter an issue downloading machine-readable files, it may be helpful to switch to another internet browser type.
Understanding the Data
Machine-readable files published by Arkansas Blue Cross and Blue Shield and its affiliates conform to the technical implementation guide and schema version 1.0.0 published by the federal Centers for Medicare & Medicaid Services (CMS) at https://github.com/CMSgov/price-transparency-guide