CMS-10572 Data Elements - Appendix A1

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Appendix A1. Transparency in Coverage Reporting by Qualified Health Plan Issuers - Plan Year 2023

General Information
Was this Issuer on the Exchange in 2021?*
SADP Only?*
Issuer HIOS ID*
Issuer Level Data
Number of Issuer Level Claims with Date(s) of Service (DOS) in 2021 That Were Also Received in Calendar Year 2021*
Number of Issuer Level Claims with DOS in 2021 That Were Also Denied in Calendar Year 2021*
Number of Issuer Level Internal Appeals Filed in Calendar Year 2021*
Number of Issuer Level Internal Appeals Overturned from Calendar Year 2021 Appeals*
Number of Issuer Level External Appeals Filed in Calendar Year 2021*
Number of Issuer Level External Appeals Overturned from Calendar Year 2021 Appeals*
Notes:
Please enter any comments/notes here.

OMB Control # 0938-1310
Expiration Date: XX/XX/20XX
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 212441850. ****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].

Press TAB and directioAll fields with an asterisk ( * ) are required. To validate the template, press Validate button or Ctrl + Shift + I. To finalize the template, press Finalize button or Ctrl + Shift + F.
All plan IDs submitted via Plans & Benefits Template(s) must be included in this template.
DRAFT Centers for Medicare & Medicaid Services (CMS) Qualified Health Plan (QHP) Transparency in Coverage Reporting
Plan Year 2023
Plan Level Data

Plan ID*

Number of Plan Level
Claims with DOS in 2021
That Were Also
Received in Calendar
Year 2021*

Number of Plan Level
Claims with DOS in 2021
That Were Also Denied
Due to Prior
Number of Plan Level
Claims with DOS in 2021 Authorization or
That Were Also Denied Referral Required in
in Calendar Year 2021* Calendar Year 2021*

Number of Plan Level
Claims with DOS in 2021
That Were Also Denied
Due to an Out-OfNetwork
Provider/Claims in
Calendar Year 2021*

Number of Plan Level
Claims with DOS in 2021
That Were Also Denied
Due to Exclusion of a
Service in Calendar Year
2021*

Number of Plan Level
Claims with DOS in 2021
That Were Also Denied
Due to Lack of Medical
Necessity, excluding
Behavioral Health in
Calendar Year 2021*

Number of Plan Level
Claims with DOS in 2021
That Were Also Denied
Due to Lack of Medical
Necessity, Behavioral
Health only, in Calendar
Year 2021*

Number of Plan Level
Claims with DOS in 2021
That Were Also Denied
for "Other" Reasons in Notes: (Please enter any
Calendar Year 2021*
comments/notes here.)