Form CMS-10572 QHP Issuer Data Collection and Display

Transparency in Coverage Reporting by
Qualified Health Plan Issuers
(CMS-10572)
Appendix A – QHP Issuer Data Collection and Display
Section A – QHP Issuer Data Collection and Display Overview
This chart lists the specific data elements CMS proposes to collect and display for 2016 through
2018 and a description of the data elements. More detail on the data elements to be collected is
provided in section B, below.
Data Collection
Element Name

Data Element Description

Issuer Name

The issuer’s full legal name, as submitted in the Qualified Health Plan
(QHP) application.

Issuer D/B/A, if
Applicable

Business name(s) under which issuer offers QHP(s) on the Federallyfacilitated Marketplace, if different from Issuer Name.

2016

Issuer ID

The issuer’s 5-digit Health Insurance Oversight System (HIOS) ID.

2016

Contact Name

2016

Contact E-mail

The contact person on the issuer’s staff who the Centers for Medicare and
Medicaid Services (CMS) should contact with any questions regarding
this data collection.
The backup contact person on the issuer’s staff who CMS should contact
with any questions regarding this data collection, in the event that primary
contact is unavailable.
The e-mail address for the contact name and backup contact.

Contact Telephone

The telephone number for the contact name and backup contact.

2016

Claims Payment
Policies and Practices
and Other Information
as Determined
Appropriate by the
Secretary

Issuers will provide one URL link to policies on their websites on: out-ofnetwork liability and balance billing; enrollee claim submission; grace
periods and claims pending; retroactive denials; recoupment of
overpayments; medical necessity and prior authorization timeframes and
enrollee responsibilities; drug exception timeframes and enrollee
responsibilities 1; explanations of benefits (EOBs); and coordination of
benefits (COB).
The number of claims denied, the number of internal and external appeals
filed, and the disposition of the appeals.
Issuer-level disenrollment figures.

2016
(optional),
2017
(required)

Data Display Element
Name

Data Element Description

Claims Payment
Policies and Practices
and Other Information
as Determined

URL link to policies on issuer websites on: out-of-network liability and
balance billing; enrollee claim submission; grace periods and claims
pending; retroactive denials; recoupment of overpayments; medical
necessity and prior authorization timeframes and enrollee responsibilities;

Year in which
Display of
Element will
Begin
2016 for
issuers that opt
to submit a
URL; 2017 for
all issuers

Backup Contact Name

Claims Denials
Data on Disenrollment

1

Year in which
Collection of
Element will
Begin
2016

2016

2016

2017
2017

Not required for stand-alone dental plans

1

Appropriate by the
Secretary
Claims Denials
Periodic Financial
Disclosures

Data on Enrollment

Data on Disenrollment
Data on Rating
Practices
Information on Costsharing and Payments
for Out-of-network
Coverage
Information on Enrollee
Rights under Title I

drug exception timeframes and enrollee responsibilities 2; EOBs; and
COB.
The number of claims denied; the number of internal and external appeals
filed; and the disposition of the appeals.
QHP issuers currently submit financial information to the National
Association of Insurance Commissioners (NAIC). CMS would link to
prior calendar year issuer-level information about premiums, assets, and
liabilities that the NAIC currently collects and displays, and which is
currently publicly available. CMS would display this link in a public use
file (PUF). No issuer submission is required.
CMS would provide issuer-level enrollment numbers as derived from
HealthCare.gov. Data enrollment numbers will be based on the end of the
prior calendar year’s information. CMS will provide this information in a
PUF. No issuer submission is required.
Issuer-level disenrollment figures.
CMS currently provides plan-level Unified Rate Review data that it
collects annually and displays on Data.HealthCare.gov. No issuer
submission required.
HealthCare.gov currently links to an issuer’s current year Summary of
Benefits and Coverage (SBC). The SBC includes information on cost
sharing, including cost sharing for out-of-network services. No issuer
submission required.
CMS currently provides this information on enrollee rights and protections
on HealthCare.gov, which is available at
https://www.healthcare.gov/health-care-law-protections/. No issuer
submission required.

2017
2016

2016

2017
N/A; CMS
currently
displays this
N/A; CMS
currently
displays this
N/A; CMS
currently
displays this

Section B – Detailed Information on Data to be Collected
•

Claims payment policies and practices.
• Information provided on the QHP issuer’s website should include issuer-level
policies applicable to QHP enrollees on the following. QHP issuer reporting is
optional for plan year 2016 and required thereafter. If a QHP issuer voluntarily
provides this information on its website, it should submit one URL for this
information and other information as the Secretary may require, which CMS will
display in a PUF.
Out-of-network liability and balance billing
Description of the data element:
 Balance billing occurs when an out-of-network provider bills an
enrollee for charges – other than copayments, coinsurance, or any
amounts that may remain on a deductible.
Issuers will provide the following:
 Information regarding whether an enrollee may have financial
liability for out-of-network services.
 Any exceptions to out-of-network liability, such as for emergency
services.

2

Not required for stand-alone dental plans

2



Information regarding whether an enrollee may be balance-billed.
Issuers do not need to include specific dollar amounts for out-ofnetwork liability or balance billing.

Enrollee claims submission
Description of the data element:
 An enrollee, instead of the provider, submits a claim to the issuer,
requesting payment for services that have been received.
Issuers will provide the following:
 General information on how an enrollee can submit a claim in lieu
of a provider, if the provider failed to submit the claim. If claims
can only be submitted by a provider, this should be indicated as
well.
 A time limit to submit a claim, if applicable.
 Links to any applicable forms.
 The physical mailing address and/or email address where an
enrollee can submit a claim, and a customer service phone number.
•

Other information as determined appropriate by the Secretary.
• Information provided on the QHP issuer’s website should include issuer-level
policies applicable to QHP enrollees on the following. QHP issuer reporting is
optional for plan year 2016 and required thereafter. If a QHP issuer voluntarily
provides this information on its website, it should submit one URL for this
information and claims payment policies and practices, which CMS will display
in a PUF.
Grace periods and claims pending policies during the grace period
Description of the data element:
 A QHP issuer must provide a grace period of three consecutive
months if an enrollee receiving advance payments of the premium
tax credit has previously paid at least one full month's premium
during the benefit year. During the grace period, the QHP issuer
must provide an explanation of the 90 day grace period for
enrollees with premium tax credits pursuant to 45 CFR 156.270(d).
Issuers would provide the following:
 An explanation of what a grace period is.
 An explanation of what claims pending is.
 An explanation that it will pay all appropriate claims for services
rendered to the enrollee during the first month of the grace period
and may pend claims for services rendered to the enrollee in the
second and third months of the grace period.
Retroactive denials

3

Description of the data element:
 A retroactive denial is the reversal of a previously paid claim,
through which the enrollee then becomes responsible for payment.
Issuers would provide the following:
 An explanation that claims may be denied retroactively, even after
the enrollee has obtained services from the provider, if applicable.
 Ways to prevent retroactive denials when possible, for example
paying premiums on time.
Enrollee recoupment of overpayments
Description of the data element:
 Enrollee recoupment of overpayments is the refund of a premium
overpayment by the enrollee due to the over-billing by the issuer.
Issuers would provide the following:
 Instructions to enrollees on obtaining a refund of premium
overpayment.
Medical necessity and prior authorization timeframes and enrollee
responsibilities
Description of the data element:
 Medical necessity is used to describe care that is reasonable,
necessary, and/or appropriate, based on evidence-based clinical
standards of care.
 Prior authorization is a process through which an issuer approves a
request to access a covered benefit before the insured accesses the
benefit.
Issuers would provide the following:
 An explanation that some services may require prior authorization
and/or be subject to review for medical necessity.
 Any ramifications should the enrollee not follow proper prior
authorization procedures.
 A time frame for the prior authorization requests.
Drug exceptions timeframes and enrollee responsibilities
Description of the data element:
 Issuers’ exceptions processes allow enrollees to request and gain
access to drugs not listed on the plan’s formulary, pursuant to 45
CFR 156.122(c).
Issuers would provide the following:
 An explanation of the internal and external exceptions process for
people to obtain non-formulary drugs.

4




The time frame for a decision based on a standard review or
expedited review due to exigent circumstances.
How to complete the application.

Information on Explanations of Benefits (EOBs)
Description of the data element:
 An EOB is a statement an issuer sends the enrollee to explain
what medical treatments and/or services it paid for on an
enrollee’s behalf, the issuer’s payment, and the enrollee’s
financial responsibility pursuant to the terms of the policy.
Issuers would provide the following:
 An explanation of what an EOB is.
 Information regarding when an issuer sends EOBs (i.e., after it
receives and adjudicates a claim or claims).
 How a consumer should read and understand the EOB.
Coordination of benefits (COB)
Description of the data element:
 Coordination of benefits exists when an enrollee is also covered
by another plan and determines which plan pays first.
Issuers would provide the following:
 An explanation of what COB is (i.e., that other benefits can be
coordinated with the current plan to establish payment of
services).
Issuer contact information
Description of the data element:
 Issuers would provide appropriate contact information so that
CMS can follow up with the appropriate point of contact with the
issuer in the event of any questions.
Issuer would provide the following:
 Main point of contact, phone number, and email address.
•

Claims Denials
• Starting with the 2017 plan year, issuers would provide to CMS information
regarding denied claims. Issuers would provide:
 The total number of claims denied in the preceding calendar
year, for any reason, both as a number and a percentage of all
claims submitted.
 The number of internal coverage appeals filed by enrollees in
the preceding calendar year, both as a number and a percentage

5






•

of all claims submitted (i.e., what percent of all claims
submitted enrollees appealed).
The number of internal coverage appeals in which the initial
denial is overturned, both as a number and a percentage of all
internal appeals filed.
The number of external coverage appeals filed by enrollees in
the preceding calendar year, both as a number and a percentage
of all claims submitted (i.e., what percent of all claims
submitted enrollees appealed externally).
The number of external coverage appeals in which the initial
denial is overturned, both as a number and a percentage of all
internal appeals filed.

Data on Disenrollment
• Starting with the 2017 plan year, issuers would provide to CMS information
regarding disenrollment. Issuers would provide the total number of
disenrollment’s for the preceding calendar year, both as a number and a
percentage of all enrollees.

6