By Kaitlin Howard
Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.
The Departments of Health and Human Services, Labor, and the Treasury finalized the Transparency in Coverage Rule requiring health insurers and employer self-insured health plans to create a member-facing price comparison tool and post publicly-available machine-readable files. These files must include in-network negotiated payment rates and historical out-of-network charges for covered items and services, including prescription drugs. The data in these files are required to be updated monthly.
With the January 1, 2022 deadline, you’re probably knee-deep in preparation for the Transparency in Coverage (TiC) mandate. But, as we’re sure you know, there’s a lot to prepare.
Let’s take a look at the requirements and important considerations for the Machine-Readable Files mandate.
Each file needs to include specific information around covered items, services, and prescription drugs for in- and out-of-network provider rates.
In-network negotiated rate files
For this file, rates for items and services of all contracted providers need to be included. If a plan uses leased networks, data must be blended with local network data, resulting in one compliant machine-readable file.
Each listed rate should be associated with the National Provider Identifier (NPI), Tax Identification Number (TIN), and Place of Service Code for each provider and the last date of the contract term or expiration date.
If a plan uses a standard fee-for-service model or other reimbursement arrangements (e.g. bundled payment arrangements), the primary billing code and total cost for the bundle must be identified in the file, as well as the list of services included.
Out-of-network allowed amount files
Like in-network negotiated rate files, each rate for services and items must be associated with the NPI, TIN, and Place of Service Code for each out-of-network provider. What’s different, however, is only historical payments for providers with more than 20 claims in the first 90 of the preceding 180 days need to be included. Out-of-network drug pricing will also need to be included.
In-network negotiated prescription drug files
For each covered option, the National Drug Code (NDC) and the proprietary and nonproprietary name assigned to this code by the FDA should be included. And just like the other files, for each NDC, negotiated rates must be provider-specific and associated with the NPI, TIN, and Place of Service Code, as well as the last date of the contract term or expiration date for each rate. Historical net prices associated with the 90-day period beginning 180 days prior to the publication of the file also need to be included.
All-Encompassing File Specifications
In addition to the above-mentioned file-specific requirements, there are many common ones that should be on your radar.
Specific guidelines include:
Name and identifier
Each file must include the name of the coverage option and the associated identifier, which should be either the Health Insurance Oversight System (HIOS) number or the related Employer Identification Number (EIN) if the first is unavailable.
Billing / Rx code
Billing codes (e.g. CPT, HCPCS, etc) for services and items or the National Drug Code (NDC) for prescription drugs must be included.
Rates for all items, services, and prescription drugs need to be displayed in dollar amounts.
To ensure data integrity, all files must conform to a non-proprietary, open standard format, like JSON, XML, or YAML, and be made available via HTTPS. Dates, file names, and file type names need to follow set standards to meet mandate requirements. The Centers for Medicare & Medicaid Services has a technical implementation guide which can be found here: https://github.com/CMSgov/price-transparency-guide.
Files should be made available to the public without restrictions that may impede information re-use. Search engine discoverability and accessibility to internet-based and mobile application developers must be ensured to support development of innovative consumer-facing tools, as well as to other entities (e.g. researchers, regulators, etc.).
The Wrap Up
While there are many questions to consider before implementation, be sure to include considerations beyond file types and data elements. Do you want to create, blend, and host all your files? Should outside vendors handle this to leave room for team member collaboration on strategic initiatives? Would it be helpful to work with a PBM who supplies a compliant Rx file, so you only provide the remaining two machine-readable files?
Regardless of how you decide to meet compliance, Zelis is here to help.
To further explore getting started with NSA and TiC compliance, reach out to your Zelis representative or contact us here.
For access to additional information, visit Zelis No Surprises Act Information Hub.
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