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HealthEdge Source™ and Machine-Readable Files for Transparency

Costs for healthcare services are often a mystery until after treatment or services have been implemented and a bill is issued. The Transparency in Coverage (TiC) regulations set by the U.S. Departments of Labor, Treasury, and Health and Human Services in October 2020 aims to make rates more readily available for cost comparison by healthcare consumers.

To stay up to date with TiC regulations, the HealthEdge Source™ team has developed a comprehensive solution that focuses on:

  • Adherence to CMS mandate
  • Recognition of customer nuances
  • Customization of requirements including schedule to match system capabilities with customer needs
  • Ability to generate MRFs that include rates specific to selected configurations
    • Rates are generated based on:
      • Medicare payment systems for Professional and Institutional Provider Types.
      • Commercial payment methodology, as configured in your Source environment.
      • Schedules and parameters that you configure within the Source application.

The TiC functionality within HealthEdge Source leverages existing configurations to adhere to the CMS mandate by automatically generating machine-readable files (MRFs) that are specific to those configurations. For example, if a customer is using a configuration that has 105% of Medicare professional rates, this would be reflected in that customer’s MRFs. Customers will be able to select the configuration, the state, the provider type, if necessary, and users can add subscribers to the message alerts when files are ready in a pre-determined location to be picked up by a SFTP process.

Below, I’ve addressed some common questions our customers have about working with MRFs in HealthEdge Source.

Q: What is an MRF?

A: An MRF is a digital representation of information. The TiC regulations require MRFs in an open-standard format that can be used for sharing with healthcare consumers, for example, on a portal or website. HealthEdge Source supports the JSON format, which complies with the CMS requirement.

Q: What is the basis for creating MRFs in Source?

A: MRFs can be created for contracts that have been set up as configurations in Source. The rates produced in MRFs will be based on configuration-specific provider type and payment methodology.

Q: Is HealthEdge Source able to produce rates more specific than configuration-based rates?

A: Yes. The system can produce rates based on services (billing codes) and modifiers included in CMS fee and data schedules.

Q: How frequently can MRFs be generated?

A: HealthEdge Source can generate files monthly per CMS mandate and per customer need. The generation of files may be scheduled in advance by product end-users to support timely delivery of rate updates.

Q: How will rates be accessed?

A: Rates that appear on an MRF will be accessed as JSON based files via SFTP. An email notification can be configured when files are ready to be picked up. Due to file size, the file itself will not be emailed; however, a link to where files are housed will be provided.

Q: What types of rates do MRFs contain?

A: TiC MRFs consist of rate schedules for healthcare items and services. These rate schedules are based on your HealthEdge Source configurations and include the in-network and negotiated rates per your provider contracts as well CMS rates and policy data for all localities and ZIP codes. Each rate schedule covers a type of billing code, including case-mix group (CMG), HCPCS, CPT®, HIPPS, MS-DRG, and revenue code (RC).

Q: Is this feature licensed?

A: The capability to generate MRFs is available for all HealthEdge Source clients; however, a license is needed to turn it on in your environment.