Internet-based Self-Service Tool

OMB Control No. 0938-New
Expiration Date: XX/XX/XXXX

APPENDIX 3:
The Allowed Amount Machine-Readable File
Data Elements
The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have
proposed requiring group health plans and health insurance issuers (plans and issuers) in the individual
and group markets to disclose certain pricing information. Under the proposed rules, a plan or issuer
must disclose certain data elements to the public, including allowed amounts for out-of-network
providers, through a machine-readable file posted on an internet website. The table below identifies
data elements that a plan or issuer would be required to include in each allowed amount machinereadable file.
DATA ELEMENT

DESCRIPTION

General Information
Name of Reporting Entity 1

The legal name of the entity publishing the machine-readable file.

Type of Entity

The type of entity that is publishing the machine-readable file (a
group health plan, health insurance issuer, or a third party with
which the plan or issuer has contracted to provide the required
information, such as a third-party administrator, a health care claims
clearinghouse, or a health insurance issuer that has contracted with
a group health plan sponsor).

Date of Last File Update

The date on which the machine-readable file was last updated.

Identification of Plan or Coverage
Plan or Coverage Name

The plan name and name of plan sponsor and/or insurance company
(for example, “Maximum Health Plan: Alpha Insurance Group”).

Plan Identifier

The Employer Identification Number (EIN) or the Health Insurance
Oversight System Identification Number (HIOS ID), as applicable, for
each plan option or coverage offered by a group health plan or
health insurance issuer.

Type of Plan Identifier

The EIN or HIOS ID, as applicable.

A plan or issuer may contract with a third party (such as a third party administrator, a health care claims
clearinghouse, or a health insurance issuer that has contracted with a group health plan sponsor) to satisfy the
disclosure requirements, subject to the requirements in the proposed rules.

1

DATA ELEMENT

DESCRIPTION

Type of Plan Market

The type of market in which the plan is offered (individual or group
market coverage).

Type of Product Network

The particular type of product network (for example, health
maintenance organization, preferred provider organization, exclusive
provider organization, or point of service) through which a group
health plan or health insurance issuer offers a discrete package of
health coverage.

Network Name

The name of the network through which a group health plan or
health insurance issuer offers a discrete package of health coverage.

Identification of Providers
Provider Name

The legal name of the person or entity associated with a National
Provider Identifier (NPI).

NPI

The unique 10-digit identification number issued to a provider by the
Centers for Medicare & Medicaid Services.

Provider Zip Code

The postal ZIP code of the physical location where the servicing
provider renders items or services or dispenses prescriptions. May
include non-U.S. ZIP codes. For U.S. ZIP codes, the ZIP+4 (also
referred to as the "plus-four" or "add-on" code) must be included. A
complete record of each of the data elements listed in this table
must be separately reported for each separate physical location of a
provider.

Historical Out-of-Network Allowed Amounts

DATA ELEMENT

DESCRIPTION

Unique Out-of-Network
Allowed Amount

Each unique allowed amount, reflected as a dollar amount, that a
group health plan or health insurance issuer paid for a covered item
or service furnished by an out-of-network provider during the 90-day
time period that begins 180 days prior to the publication date of the
machine-readable file. The allowed amount would be reported as
the aggregate of the actual amount the plan or issuer paid to the
out-of-network provider for a particular covered item or service, plus
the participant’s, beneficiary’s, or enrollee’s share of the cost. To
protect patient privacy, a plan or issuer must not provide out-ofnetwork allowed amount data for a particular provider and a
particular item or service when compliance would require the plan
or issuer to report out-of-network allowed amounts for a particular
provider in connection with fewer than 10 different claims for
payment. Issuers, service providers, or other parties with which the
plan or issuer has contracted may aggregate out-of-network allowed
amounts for more than one plan or insurance policy or contract. If
information is aggregated, the 10 minimum claims threshold would
apply to the aggregated claims data set, and not at the plan or issuer
level.

NPI Associated with Allowed
Amount

The NPI associated with each provider-specific allowed amount for
each covered item or service included in the machine-readable file.

Identification of Items and Services

Billing Code

The code used by a group health plan or health insurance issuer or
its in-network providers to identify health care items or services for
purposes of billing, adjudicating, and paying claims for a covered
item or service.

Type of Billing Code

The types of billing codes include the Current Procedural
Terminology (CPT) code, Healthcare Common Procedure Coding
System (HCPCS) code, Diagnosis-Related Group (DRG) code, National
Drug Code (NDC), or other common payer identifier.

Billing Code Type Version

Any version designation associated with the billing code type. For
example, Medicare is currently using the International Classification
of Diseases (ICD) version 10.

Bundle Indicator

Indication as to whether the billing code applies to a bundle of items
and services under a bundled payment arrangement or whether the
billing code only applies to a singular item or service.

Covered
Items and Services

The name of each item or service for which the costs are payable, in
whole or in part, under the terms of the group health plan or health
insurance coverage.

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The Departments are seeking OMB approval
for the model as part of the approval for a new OMB control number 0938-NEW. The time required to
complete this information collection is estimated to average 1,290 hours per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.