Machine Readable Files
The United States Departments of Health and Human Services (HHS), Labor and Treasury issued a Final Rule entitled Transparency in Coverage (the Final Rule) on November 12, 2020. The Final Rule applies to non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets. The Final Rule requires that plans and issuers post three separate publicly available machine-readable files disclosing in-network negotiated rates, historical out-of-network allowed amounts, and drug pricing information. Plans and issuers must post the in-network negotiated rates and historical out-of-network allowed amounts files on or before July 1, 2022, however the drug pricing file requirement has been deferred pending future rulemaking.
Additional information and resources regarding the Transparency in Coverage Final Rule can be found here:
- Transparency in Coverage Final Rule Fact Sheet (CMS-9915-F)
- Transparency in Coverage Final Rule
- CMS Transparency in Coverage Website
- CMS Transparency in Coverage Resources
GHC-SCW will publish machine-readable files in the JSON format. File Schema information is available on github.com: https://github.com/CMSgov/price-transparency-guide.
GHC-SCW produces and posts the required machine-readable files on GHC-SCW’s public website for all fully-insured groups. Files are located at https://mrf.azureedge.net.
Files are publicly-accessible and free of charge. No user account, password, credential, or identifying information is required to access the files.
Groups may link to GHC-SCW’s public website, ghcscw.com/transparency-in-coverage and or https://mrf.azureedge.net, or download and post the files on their own site.
Files will be released every month and will be stamped with the latest file update date. The updated file(s) will also replace the previous file. Pricing included in data contained in posted machine-readable files is accurate as of the date it is extracted but may change before the next update of the files.
To submit questions or technical support requests related to machine-readable files, please email MRF@ghcscw.com.
Identifying Applicable Files
Negotiated Rates Files: The Negotiated Rates Files utilize “Representative Groups”. Use the Index File (YYYY-MM-DD_ghc_index.json) to identify the appropriate Negotiated Rates File. Reference the file schema for details on how to use the JSON Index File. File Schema information is available on github.com: https://github.com/CMSgov/price-transparency-guide. To find the applicable Negotiated Rate File in the Index File you will need your group number(s). If you need assistance identifying your group number(s) for the Index, refer to your premium billing invoice or contact the GHC-SCW Enrollment Department at (608) 251-4138.
While not included in the Index File, PPO plans may also reference the following files:
Allowed Amount Files: In addition to group specific Allowed Amount Files, POS and PPO plans may also reference the following files:
Note: Allowed Amount Files are generated regardless of whether the group has met applicable claims thresholds during the look-back period. In the event the claims threshold was not met, the group specific Allowed Amount File will be empty.
Pricing data in posted machine-readable files is not a guarantee of payment and may not match amounts that appear on final documentation after claims are fully processed.
Machine-readable files may include NPIs and/or TINs. You are encouraged to apply for a new TIN if you presently use a SSN as your TIN.