CMS-10572 Data Submission Template - Appendix C

OMB Control # 0938-1310
Expiration Date: XX/XX/20XX

Transparency in Coverage Reporting by Qualified Health Plan Issuers
Appendix C – Claims Payment Policies and Practices URL
URL Element Name
Out-of-network
liability and balance
billing

Enrollee claim
submission

Grace periods and
claims pending

URL Element Description
Description:
• Balance billing occurs when an out-of-network provider bills
an enrollee for charges other than copayments, coinsurance, or
the amount remaining on a deductible.
Provide:
• Information regarding whether a consumer may have financial
liability for out-of-network services.
• Any exceptions to out-of-network liability, such as for
emergency services or pursuant to the No Surprises Act.
• Information regarding whether a consumer may be balance
billed. You do not need to include specific dollar amounts for
out-of-network liability or balance billing.
Description:
• An enrollee submits a claim instead of the provider, requesting
payment for services received.
Provide:
• General information on how an enrollee can submit a claim in
lieu of a provider if the provider fails to submit the claim or
does not submit claims. If claims can only be submitted by a
provider, indicate this here.
• A time limit to submit a claim, if applicable.
• Links to any applicable forms. All forms must be easily
identifiable and publicly accessible.
• Describe how an enrollee can submit a claim if you do not
require any forms. List any identifying information such as
name, member number, and other information that an enrollee
must include for successful claim submission.
• The physical mailing address and/or email address where an
enrollee can submit a claim, and a customer service phone
number
Description:
QHP issuers 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. Issuers must pay claims during the first month of a grace

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 valid OMB control number for this information collection is 0938-1310 (Expires XX/XX/20XX). The time required to
complete a one-time technical modification is estimated to average 11 hours per response for QHP issuers. The time required to complete an
annual submission of Transparency in Coverage data is estimated to average 44 hours per response for QHP issuers. 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. ****CMS Disclosure**** Please do not send applications,
claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Jack
Reeves at [email protected].

URL Element Name

Retroactive denials

Recoupment of
overpayments

Medical necessity
and prior
authorization
timeframes and
enrollee
responsibilities

URL Element Description
period, and may pend claims during the second and third months. At
the initiation of an enrollee grace period, issuers must provide a
notification of the change in status and an explanation of the 90-day
grace period for enrollees with premium tax credits, that all
appropriate claims will continue to be paid in the first month, and
information regarding whether the issuer pends claims in the second
and third months, pursuant to 45 CFR 156.270(d).
Provide:
• An explanation of what a grace period is.
• An explanation of what claims pending is.
• An explanation that you will pay all appropriate claims for
services rendered to the enrollee during the first month of the
grace period.
• An explanation that you may pend claims for services rendered
to the enrollee in the second and third months of the grace
period.
• An explanation that you do not pend claims, if applicable.
Description:
• A retroactive denial reverses a previously paid claim, making
the enrollee responsible for payment.
Provide:
• 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, such as
paying premiums on time.
Description:
• If an issuer overbills an enrollee for a premium, they may use
recoupment of overpayments to obtain a refund.
Provide:
• Instructions on how enrollees can obtain a refund of premium
overpayment, including a phone number or email address they
should contact.
Description:
• Medical necessity is used to describe care that is reasonable,
necessary, and appropriate, based on evidence-based clinical
standards of care.
• Prior authorization is a process by which an issuer approves a
request to access a covered benefit before the enrollee accesses
the benefit.
Provide:

URL Element Name

Drug exception
timeframes and
enrollee
responsibilities (not
required for SADPs)

Explanation of
benefits (EOB)

Coordination of
benefits (COB)

URL Element Description
• An explanation that some services may require prior
authorization and may be subject to review for medical
necessity.
• An explanation of any ramifications should the enrollee not
follow proper prior authorization procedures.
• A timeframe for the issuer to provide a response to the enrollee
or provider’s prior authorization request, including urgent
requests as applicable.
Description:
• 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).
Provide:
• An explanation of the internal exceptions process for people to
obtain non-formulary drugs.
• An explanation of the external exceptions process for people to
obtain non-formulary drugs through external review by an
impartial, third-party reviewer, or Independent Review
Organization (IRO).
• Timeframes for decisions based on standard reviews and
expedited reviews due to exigent circumstances.
• Instructions on how to submit required information to start the
exceptions process. This includes a request form link, address,
phone number, or fax number for the enrollee to contact.
Description:
• An EOB is a statement an issuer sends an enrollee that lists the
medical treatments or services paid for on an enrollee’s behalf,
what was paid, and the enrollee’s financial responsibility
pursuant to the terms of the policy.
Provide:
• An explanation of what an EOB is.
• Information regarding when an issuer sends EOBs (e.g., after it
receives and adjudicates a claim or claims).
• How a consumer should read and understand the EOB.
• An example EOB for illustrative purposes.
Description:
• COB allows an enrollee who is covered by more than one plan
to determine which plan pays first.
Provide:
• An explanation of what COB means (i.e., that other benefits
can be coordinated with the current plan to establish payment
of services).