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
Data Element Name

Data Element Description

Issuer Name 1

The issuer’s full legal name, as submitted in the Qualified Health Plan
(QHP) application.
Business name(s) under which issuer offers QHP(s) on the Federallyfacilitated Marketplace, if different from Issuer Name.
The issuer’s 5-digit Health Insurance Oversight System (HIOS) ID.
The issuer’s 14-alpha-numeric ID.
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.
The telephone number for the contact name and backup contact.

Issuer D/B/A, if
Applicable1
Issuer ID1
Plan ID1
Contact Name 1

Backup Contact
Name1
Contact E-mail1
Contact Telephone1
Claims Payment
Policies and Practices
and Other
Information as
Determined
Appropriate by the
Secretary1

Issuer-Level Claims
Data1

Plan-Level Claims
Denial2

1

Issuers will provide one URL link titled “Transparency in Coverage”
to policies on their main 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; drug exception timeframes and enrollee
responsibilities; explanations of benefits (EOBs); and coordination of
benefits (COB), as explained in section IV of the Supporting
Statement.
Issuers will provide: claims received; claims denied; internal appeals
filed; internal appeals overturned; percent of internal appeals
overturned; external appeals filed; external appeals overturned; and
percent of external appeals.
Issuers will provide plan level claims denials based on the following
denial categories: 1.) Referral or prior authorization required, 2.) Out
of network provider/claims, 3.) Services excluded or not covered, 4.)
Not medically necessary, excluding behavioral health, 5.) Not
medically necessary, including behavioral health, and 6.) Other.

Approved on June 16, 2016 OMB Control #0938-1310