Preparations for Transparency in Coverage compliance are in full swing, especially when it comes to Phase I of the mandate, machine-readable files (MRFs). Although enforcement of MRFs is deferred, giving health plans and groups six more months to comply, there is still plenty of work to do. One major challenge is to overcome issues associated with the MRF data schema, which is key for compliant files.
In my last blog I addressed issues related to file size, data redundancy, and the protection of personal identifiable information (PII) and our proposed changes to the schema. Since then, CMS implemented schema changes based on industry feedback, including ours. For health plans interested in staying up to date, changes, questions, and feedback are posted by CMS on GitHub in real-time and CMS also hosts webinars to announce these changes.
Below is an update on the recently made schema changes. Some mark major updates that health plans need to be aware of. I also highlighted some of the benefits of each change.
- Service code attributes: The service code is displayed in the schema of both the in-network and allowed amounts files. To reduce file sizes and eliminate file duplications the service code was removed from the negotiated rates objects and added to the negotiated price objects. In addition, the type was also changed from a single string representing a single service code to an array of strings, allowing for multiple service code groupings. These modifications substantially decrease the size of MRFs and eliminate duplication of data. For further optimization CMS is likely going to announce additional changes since they are currently discussing whether service codes are applicable in all situations.
- Combine multiple plan IDs: Initially, CMS required that files be organized by plan ID, which would lead to massive data duplication. Since they realized that the same sets of rates often apply to the same provider, they followed another of our recommendations to further help downsize files and use data more efficiently. They introduced an attribute which is an array to allow for multiple plan objects to be included in a single file that have the same underlying negotiated rates and allowed amounts, respectively.
Expect additional schema changes from CMS here, including for naming convention and reference files.
- Replacements for SSN: Social security numbers (SSN) are considered protected PII and to avoid violations of the Privacy Act they should not be included in MRFs. However, there are still providers who use their SSN as their Tax Identification Number (TIN), which is a required data field within the MRF schema. To protect PII and avoid the risk of identity theft, CMS followed another of our recommendations and announced that providers should report either their national provider identifier (NPI) or their employer identification number (EIN), as issued by the IRS, as TIN instead of their SSN for both negotiated rates and claims adjudication.
As mentioned above, there are certainly more changes to come. While CMS continues to make updates to the data schema until version 1.0.0 is published on March 1, 2022, we are actively working with our clients to get them ready for MRF compliance. The work required to meet mandates, even amidst a shifting landscape, requires that plans be actively working now to prepare.
If you have questions about the MRF schema, concerns about price transparency compliance, or aren’t sure where to start to be ready for the MRF enforcement date of July 1, 2022, reach out to us. Our experts continue to monitor for any upcoming changes, stay in touch with our contacts at CMS, and keep our clients up to date to avoid any possible implications.
