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Transparency
in Coverage
ABA and the transparency in
Coverage Final Rule – An Overview
Working with ABA, you know we’ve always been about delivering more than
just benefits. We constantly strive to provide you with all the information you
need to make informed decisions for your client companies.
As such, we want to bring you up to speed on the transparency in Coverage Final Rule that goes into effect on July 1, 2022 for group health plans network insurance carriers. The act has been set forth by the U.S. Department of the Treasury, the U.S. Department of Labor and the U.S. Department of Health and Human Services (The «Tri-Agencies»).
What is the act? 
The Transparency in Coverage Final Rule Act requires group health plans and health insurance issuers to make information available to the public so consumers can better understand healthcare, pricing and the cost for healthcare services. Consumers must be empowered to shop and compare cost and make price-conscious decisions.
Here is what must be included: 
- Negotiated rates for all covered items with in-network providers
- Each listed rate needs to be provider-specific and associated with the National Provider Identifier (NPI), Tax Identification Number (TIN) and Place of Service Code for each provider, including the last date of the contract term or expiration date.
- Historical payments to – and billed charges from – out-of-network providers through machine-readable files (MRFs) posted on an internet website, updated monthly
- Similar to in-network negotiated rate files, each rate for services and items needs to be associated with the NPI, TIN, and Place of Service Code for each out-of-network provider.
A third required MRF disclosing negotiated rates and historical net prices for covered prescription drugs is currently delayed, but is on the horizon.
Please note: These files must be available free of charge, without having to establish a user account password, credentials or submit personal information.
Below you’ll find a link to each of our provider’s network MRF:
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What is a machine-readable file (MRF)? 
Machine-readable data is described as «data in a format that can be easily processed by a computer without human intervention while ensuring no semantic meaning is lost.» (Please note, “Machine Readable” is not synonymous with digitally accessible.)
Machine-readable data is classified in two groups:
- Human-readable data marked in such a way so that it can also be read by machines, including microformats, RDFa, HTML).
- Data File formats are intended principally for processing by machines (CSV, RDF, XML, JSON) These formats are only machine readable if the data contained within them is formally structured.
Required content elements for all MFR’s 
- Name and identifier for each coverage option: Plans and issuers must include their Health Insurance Oversight System (HIOS) ID at the 14-digit product level. If the plan or issuer does not have a HIOS ID at the plan or product level, the plan or issuer must use the HIOS ID at the five-digit issuer level. If a plan or issuer does not have a HIOS ID, it must use its EIN.
- Billing codes: This includes a Current Procedural Terminology (CPT) code, a Healthcare Common Procedure Coding System (HCPCS) code, a Diagnosis Related Group (DRG), a National Drug Code (NDC) or another common payer identifier used by a plan or issuer (for example, a hospital revenue code). In the case of prescription drugs, plans may only use the NDC as the billing code type. Plain language descriptions of the billing codes must also be provided.
ABA will publish machine-readable files to its website monthly
Please also note:
- Fully-Insured Plans: Employers sponsoring fully insured medical plan options can rely on the insurance carrier to satisfy this requirement.
- Self-Insured Plans: Employers sponsoring self-insured medical plans should be prepared to post a link on their own company public-facing website to ensure the file is publicly available.
For your reference, here is a pdf of the Final Act
«https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-Transparency-in-Coverage-9915F.pdf
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