Over the last couple of years, several laws and regulations have passed requiring health plans and insurance providers to be more transparent surrounding the costs of their services. However, since January 2021, only hospitals were required to provide accessible pricing information online about the items and services they offered. Having taken effect in July 2022, the Transparency in Coverage Final Rule (CMS-9915-F) affects group health plans and health insurance issuers. This means they are now obliged to provide information surrounding service costs online in an accessible manner to all Americans. Are you ready for the Transparency in Coverage Final Rule?

The Requirements

Changes must be made in two ways:

  1. All items and services will need to be included in three1 separate comprehensive machine-readable files (MRFs):

    • In-network Rate File: In-network provider negotiated rates for covered items and services;

    • Allowed Amount File: Historical payments to and billed charges from out-of-network providers;

    • Provider reference: National Provider Identifier (NPI) and their associated Tax Identification Number (TIN) related to the negotiated price.

  2. Services offered will need to be visible in a consumer-friendly format.

These changes will allow patients to estimate the total cost of the services they seek and make better-informed healthcare choices.

Compliance with this new law goes further than ensuring the optimal consumer experience—noncompliant hospitals and organizations may be subject to fines.

The Solution

To meet the compliance timelines, ArtiSoft’s JetStore platform can automate the generation of machine-readable files according to the CMS-provided schemas by merging data from multiple sources, such as spreadsheets, databases, and flat files—on a monthly basis—as required by the regulation.

By using a craftsmanship approach at solving complex and/or time sensitive issues and with our 20+ years of experience in managing Health IT projects from inception to delivery, we distinguish ourselves from large technology companies.

The Team

ArtiSoft is a Montreal-based startup founded by technologists with extensive experience in processing healthcare data. We also offer consultation services focused on client satisfaction.

From Load to Ship in a Snap with JetStore

  1. A fourth upcoming requirement, which has been indefinitely postponed, is the Prescription Drug File: In-network negotiated rates and historical net prices for covered prescription drugs. ↩