CMS-10715: Appendi APPENDIX 3: The Allowed Amount Machine-Readable File Dat

OMB Control No. 0938-1372
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 issued the Transparency in Coverage final rules (85 FR 72158), which require group health
plans and health insurance issuers in the individual and group markets (plans and issuers) to
disclose certain pricing information. Under the final rules, at 26 CFR 54.9815-2715A3(b), 29
CFR 2590.715-2715A3(b), and 45 CFR147.212(b), a plan or issuer must disclose allowed
amounts and billed charges for out-of-network providers through a machine-readable file posted
on an internet website. Out-of-network allowed amount and billed charge are defined at 26 CFR
54.9815-2715A1, 29 CFR 2590.715-2715A1, and 45 CFR 147.210. The table below identifies
data elements that a plan or issuer is required to include in each machine-readable Allowed
Amount File. 1
DESCRIPTION

DATA ELEMENT
General Information

Blank

Name of Reporting Entity 2

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 the machine-readable file was last updated.

For more technical implementation guidance for this machine-readable file, please see the GitHub website space
established by the Departments. GitHub is a website and cloud-based service that helps developers store and manage
their code, as well as to track and control changes to their code. The GitHub space offers the Departments the
opportunity to collaborate with industry, including regulated entities, and third-party developers to ensure the file
format is adapted for reporting of the required public disclosure data for various plan and contracting models. The
GitHub space is available at: https://github.com/CMSgov/price-transparency-guide.
2
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 final rules.
1

DATA ELEMENT
Identification of Plan or
Coverage

DESCRIPTION
Blank

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 10-digit Health Insurance Oversight System (HIOS)
identifier, or, if the 10-digit HIOS identifier is not available,
the 5-digit HIOS identifier, or if no HIOS identifier is
available, the Employer Identification Number (EIN), for each
coverage option offered by a plan or issuer.

Type of Plan Identifier

The EIN or HIOS ID, as applicable.

Type of Plan Market

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

Identification of Providers
and Place of Service

Blank

The National Provider Identifier (NPI) Type 1 3 - The unique
10-digit identification number issued to a provider by the
Individual Provider Identifier
Centers for Medicare & Medicaid Services (CMS) to identify
individual health care providers.
Provider Group Identifier
(Required if the out-ofnetwork provider is a group
organization or pharmacy)

Tax Identifier Number (TIN)

The NPI Type 2 4 - The unique 10-digit identification number
issued to a provider by CMS for an organization of health care
providers, such as a medical group or pharmacy.

The unique identification number issued either by the Social
Security Administration or by the Internal Revenue Service
(IRS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/NPIWhat-You-Need-To-Know.pdf
4
Ibid.
3

DATA ELEMENT

Place of Service Code 5

Historical Out-of-Network
Allowed Amounts

DESCRIPTION

The CMS-maintained two-digit code that is placed on a
professional claim to indicate the setting in which a service
was provided.

Blank

Unique Out-of-Network
Allowed Amount

Each unique allowed amount, reflected as a dollar amount, that
a plan or 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 machinereadable file. The allowed amount must be reported as 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 outof-network 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 paid
to a particular provider in connection with fewer than 20
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 20 minimum claims threshold applies at the
plan or issuer level.

Billed Charge

The total charges for an item or service billed to a plan or
issuer by an out-of-network provider.

Identification of Items and
Services

Blank

“Place of Service Code Set.” Centers for Medicare & Medicaid Services. Available at:
https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.

5

DATA ELEMENT

DESCRIPTION

Billing Code

The code used by a plan or issuer or 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 identifiers.

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.

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 plan or
coverage.

Plain Language Description

Brief description of the item or service. In the case of items
and services that are associated with common billing codes
(such as the HCPCS codes), the codes’ associated short text
description may be provided. In the case of NDCs for
prescription drugs, the plain language description must be the
proprietary and nonproprietary names assigned to the NDC by
the FDA

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 Office of Management and Budget (OMB)
control number. The Departments are seeking OMB approval for the model as part of the
approval for a new OMB control number 0938-1372. The time required to complete this
information collection is estimated to average 1,651 hours per respondent, 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.