Machine-Readable Files Defined
In October 2020, The Departments of Health and Human Services, Labor and the Treasury (the Departments) finalized the Transparency in Coverage Rule. Under this rule, health plans and insurers are required to post three machine-readable files (i.e., a digital representation of data or information in a file that can be imported into or read by a computer system for further processing) on a website:
- An In-Network Rate File: negotiated rates with in-network providers
- An Out-of-Network Allowed File: historical billed charges and allowed amounts
- In-Network Prescription Drug File
These files must be accessible at no charge without requiring log-in credentials, and they must be updated monthly.
Machine-Readable File Requirements
The following information must be included on the files:
- In-Network Rate Files. In-network rates with respect to each item or service for in-network providers, including negotiated rates, underlying fee schedule rates used to determine cost-sharing, or derived amounts, whichever rate is applicable to their reimbursement model. If this rate is percentage based, the file must include the calculated dollar amount, or calculated dollar amount for each provider, identified by NPI, if rates differ by providers or network tier. The file must identify bundles of items or services by relevant code.
- Out-of-Network Allowed Files. The historical out-of-network allowed amounts for covered items or services and the billed charges for those items and services, including each unique amount, associated with the provider by NPI. If the rate is percentage based, the file must include the calculated dollar amount, and must disclose aggregate actual amounts paid, plus the individual’s share of the cost. The data in the file should encompass a 90-day period that begins 180 days prior to the publication date.
- Prescription Drug Files. Negotiated rates and historical net prices connected to prescription drugs.
Machine-Readable Files Effective Date
The requirement to post machine-readable files is effective for plan years starting on or after January 1, 2022. However, on August 20, 2021, the Departments announced that they would defer enforcement of this requirement until July 1, 2022 for In-Network and Out-of-Network files. An updated enforcement date for the Prescription Drug file hasn’t been announced.
The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes. If you have questions about how The Transparency in Coverage Final Rule applies to your organization, please consult your legal counsel.