CMS-10572 Data Templates Appendix B

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

Transparency in Coverage Reporting by Qualified Health Plan Issuers
Appendix B1 – PY23 QHP Public Use File
Issuers do not need to provide data elements marked with an asterisk (*), as CMS will provide
those elements.
Data Element Name
Issuers Name
Issuer D/B/A, if
Applicable
Issuer ID
Plan ID
Claims Payment
Policies and Practices
and Other
Information URL

Periodic Financial
Disclosure*
Data on Enrollment*
Data on
Disenrollment*
Issuer Level Claims
Data

Plan Level Claims
Data

Data Element Description
The issuer’s full legal name, as submitted in the Qualified Health Plan
(QHP) application.
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 main websites on: out-of-network liability and
balance billing; enrollee claims 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; explanation of benefits (EOB); and coordination of
benefits (COB), as explained in Section V of the Supporting
Statement and Appendix C.
URL link to National Association of Insurance Commissioners
(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).
Issuer-level disenrollment numbers as derived from the Federallyfacilitated Exchange (CMS data).
Issuers will provide:
• Claims received;
• Claims denied; and
• Appeals:
o Internal appeals filed;
o Internal appeals overturned;
o External appeals filed; and
o External appeals overturned.
Issuers will provide:
• Claims received; and
• Claims denied.

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].

Data Element Name
Plan Level Claim
Denial Data

Data Element Description
Issuers will provide:
• Claim denial reasons:
o Prior authorization or referral required;
o Exclusion of service;
o Medical necessity, excluding behavioral health;
o Medical necessity, behavioral health only;
o Out-of-network; and
o Other.