eBooks: CMS Transparency in Coverage Rule
The Transparency in Coverage Guide (CMS-9915-F) is a pivotal regulation aimed at increasing transparency in healthcare pricing, enabling consumers to access price information before receiving services
The Transparency in Coverage Guide (CMS-9915-F) is a pivotal regulation aimed at increasing transparency in healthcare pricing, enabling consumers to access price information before receiving services. This initiative, set forth 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 comparisons by healthcare consumers.
Key Implications for Payers
To comply with the Transparency in Coverage rule, payers must make negotiated charges and rates for both in-network and out-of-network services accessible. The regulation will be rolled out in three phases:
- Phase I (July 1, 2022): Implementation of in-network rate Machine Readable Files (MRF) and allowed amount rate MRF.
- Phase II (January 1, 2023): Health plans must provide an internet tool for enrollees to obtain cost information for 500 specified items and services.
- Phase III (January 1, 2024): Extension of Phase II requirements to all items and services.
Understanding Machine Readable Files (MRFs)
MRFs are digital files containing data that can be imported into computer systems for processing. They must be updated monthly and include both in-network and allowed amount rates. Compliance requires adhering to CMS-preferred file formats, such as JSON, XML, or YAML, and ensuring accurate representation of historical payments for out-of-network providers.
Compliance and Consequences
Payers must provide MRFs with accurate rates and adhere to CMS guidelines to avoid penalties and corrective actions. Our solution ensures compliance by generating MRFs tailored to specific configurations, while also offering on-demand scheduling and seamless integration with customer systems via SFTP.
Our Comprehensive Solution
Our response to the CMS mandate emphasizes:
- Adherence to compliance requirements
- Customization to match system capabilities with customer needs
- Efficient generation and management of MRFs
Implementation Strategy
Our phased rollout strategy includes:
- Assessment: Research industry standards and design workflows.
- Implementation I: Generate MRFs for facility types and configure SFTP directories.
- Implementation II: Generate MRFs for all professional provider types.
- Implementation III: Establish a separate TiC Source environment mirroring production.
Conclusion
Adopting our solution for Transparency in Coverage compliance will not only ensure adherence to the regulation requirements, but also enhance transparency, foster consumer trust, and ultimately drive better decision-making in healthcare.
