Appendix B

Transparency in Coverage Reporting by
Qualified Health Plan Issuers
(CMS-10572)
Appendix B – QHP Issuer Data Display
Data Element Name

Data Element Description

Issuer Name 1

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

Issuer D/B/A, if
Applicable1
Issuer ID1
Plan ID1
Claims Payment
Policies and Practices
and Other
Information as
Determined
Appropriate by the
Secretary1

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.
Issuers will provide one URL link titled “Transparency in Coverage”
to policies on their 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.
URL link to NAIC web page listing issuer premium receipts, assets,
and liabilities in dollar amounts.
Issuer-level enrollment numbers as derived from the Federallyfacilitated Exchange (CMS data).

Periodic Financial
Disclosure 1
Data on Enrollment1

Data on
Disenrollment1
Issuer-Level Claims
Data1

Plan-Level Claims
Denial2

Data on Rating
Practices1

1

Issuer-level disenrollment numbers as derived from the Federallyfacilitated Exchange (CMS data)
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
Unified Rate Review data file on Data.HealthCare.gov.

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

Information on Costsharing and Payments
for Out-of-network
Coverage1
Information on
Enrollee Rights under
Title I1

Summary of Benefits and Coverage (SBC) on HealthCare.gov. To
include language on out-of-network billing by requiring issuers to
explain §156.230(e) and disclosure of gag clauses.
URL to the enrollee rights and protections information provided on
HealthCare.gov at https://www.healthcare.gov/health-care-lawprotections/.