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You are probably knee-deep in preparation for the Transparency in Coverage mandate as the first deadline for machine-readable files is quickly approaching on January 1, 2022. This upcoming requirement involves sharing new data likely housed across your organization—and even outside your organization. There is a lot to prepare for, but there is no need to carry that burden all by yourself. Let’s take a look at the requirements and important considerations for the three machine-readable files.

File-specific requirements

Each of the three machine-readable files needs to include specific information around covered items, services, and prescription drugs for your in- and out-of-network provider rates. Details of the three files include:

  • In-network negotiated rate files—Unique to this file is that rates for items and services of all contracted providers need to be included. If a plan uses leased networks, it is important that these data are blended with their local network data, resulting in one compliant machine-readable file. Each listed rate needs to be provider-specific and therefore 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. If a plan uses next to a standard fee-for-service model other reimbursement arrangements like bundled payment arrangements, the primary billing code and total cost for the bundle need to be identified in the file as well as the list of services included.
  • Out-of-network allowed amount files—Like the 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. Specific to this file type is that only historical payments for providers with more than 20 claims in the first 90 of the preceding 180 days need to be included. Also, out-of-network drug pricing needs 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 need to be included. And like the other files, for each NDC the negotiated rates need to be provider-specific, associated with the NPI, TIN, and Place of Service Code, and associated with the last date of the contract term or expiration date for each of these negotiated rates. In addition to the current contract rates, historical net prices associated with the 90-day period beginning 180 days prior to the publication of the file also need to be included, unless there are fewer than 20 claims for payments.

Specifications for all machine-readable files

In addition to above-mentioned file-specific requirements, there are many common ones—from being updated every month to specific file formats and naming rules. If you are interested in being one of the first to know about possible changes to the repository, I recommend monitoring GitHub, the technical implementation guide for the tri-departmental price transparency. As of today, specific guidelines include:

  • Name and identifier—Each of the covered services and items of in-network providers need to include the name of the coverage option and the associated identifier, which should be the Health Insurance Oversight System (HIOS) number or if unavailable the related Employer Identification Number (EIN).
  • Billing/Rx Code—Billing codes like CPT, HCPCS, etc. for services and items or the National Drug Code (NDC) for prescription drugs.
  • Dollar amount—Rates for all items, services, and prescription drugs need to be displayed in dollar amounts.
  • File format—Files must conform to a non-proprietary, open standards format like JSON, XML, or YAML and made available via HTTPS to ensure the integrity of the data. Dates, file names, and file type names need to follow set standards to meet the mandate requirements.
  • Discoverability—Files need to be made available to the public without restrictions that would impede the re-use of that information. Search engine discoverability and accessibility to internet-based and mobile application developers need to be ensured to support development of innovative consumer-facing tools, as well as to other entities, such as researchers, and regulators.

Additional considerations

Aside from file types and data elements, there are other considerations for creation of the machine-readable files and making them available to the public. Do you want to create, blend, and host all your files? Do you want to have outside vendors handle this so your team can stay focused on core, strategic initiatives? Or do you work with a PBM who will supply you with a compliant Rx file and you only need help with the remaining two machine-readable files?

HealthSparq has almost a decade of experience with cost transparency and machine-readable file creation and we believe there is more to the mandate than just checking the box. We can help you to differentiate yourself in this competitive marketplace. In addition, you can deliver more than just the access to data to members, but guidance so they can make smarter healthcare choices. Contact to learn more about how we support all requirements of the Transparency in Coverage mandate and the No Surprises Act.

If you are interested in mandate-relevant resources like webinars, white papers, and my latest video around machine-readable files please visit our price transparency content hub.