CMS-10317 Appendix 2 - In-Network Rate Data Template

OMB Control No. 0938-1372
Expiration Date: XX/XX/XXXX

APPENDIX 2:
In-network Rate 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 nongrandfathered group health plans and health insurance issuers in the individual and group
markets (plans and issuers) to disclose certain cost-sharing information. Under the final rules at
26 CFR 54.9815-2715A3(b), 29 CFR 2590.715-2715A3(b), and 45 CFR 147.212(b) a plan or
issuer must disclose applicable rates for in-network providers through a machine-readable file
posted on an internet website. Applicable rates may include negotiated rates, derived amounts,
or underlying fee schedule rates, as defined by the final rules at 26 CFR 54.9815-2715A1, 29
CFR 2590.715-2715A1, 45 CFR 147.210. The table below identifies data elements that a plan or
issuer is required to include in each machine-readable In-network Rate File. 1
DATA ELEMENT

DESCRIPTION

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

DESCRIPTION

Identification of Plan or
Coverage

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

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

Individual Provider
Identifier

The National Provider Identifier (NPI) Type 1 3 - The unique
10-digit identification number issued to a provider by the
Centers for Medicare & Medicaid Services (CMS) to identify
individual health care providers.

Provider Group Identifier
(Required if the in-network
provider is a group
organization)

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.

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

DATA ELEMENT
Tax Identification Number
(TIN)

Place of Service Code

5

DESCRIPTION
The unique identification number issued either by the Social
Security Administration or by the Internal Revenue Service
(IRS).
The CMS-maintained two-digit code that is placed on a
professional claim to indicate the setting in which a service was
provided.

Applicable In-network
Rates

Blank

Negotiated Rate for each
Covered Item or Service

If applicable, the negotiated rate, reflected as a dollar amount,
for each covered item or service under the plan or coverage that
the plan or issuer has contractually agreed to pay an in-network
provider, except for prescription drugs that are subject to a feefor-service reimbursement arrangement, which must be
reported in the prescription drug machine-readable file. If the
negotiated rate is subject to change based upon participant,
beneficiary, or enrollee-specific characteristics, these dollar
amounts should be reflected as the base negotiated rate
applicable to the item or service prior to adjustments for
participant, beneficiary, or enrollee-specific characteristics.

Contract Term for
Negotiated Rate for each
Covered Item and Service

The last date of the contract term for each provider-specific
negotiated rate that applies to each covered item or service,
including rates for both individual items and services and items
and services in a bundled payment arrangement.

Derived Amount for each
Covered Item or Service

If applicable, the price that a plan or issuer assigns to an item or
service for the purpose of internal accounting, reconciliation
with providers or submitting data in accordance with the
requirements of 45 CFR 153.710(c).

“Place of Service Code Set.” CMS. Available at:
https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.
5

DATA ELEMENT

DESCRIPTION

Contract Term for Derived
Amount for each Covered
Item or Service

The last date of the contract term for each provider-specific
derived amount rate that applies to each covered item or
service, including rates for both individual items and services
and items and services in a bundled payment arrangement.

Underlying Fee Schedule
Rate for each Covered Item
or Service

If applicable, the rate for a covered item or service from a
particular in-network provider, or providers that a group health
plan or health insurance issuer uses to determine a participant’s,
beneficiary’s, or enrollee’s cost-sharing liability for the item or
service, when that rate is different from the negotiated rate.

Contract Term for
Underlying Fee Schedule
Rate for each Covered Item
or Service

The last date of the contract term for each provider-specific
underlying fee schedule rate that applies to each covered item
or service, including rates for both individual items and services
and items and services in a bundled payment arrangement.

Identification of Items and
Blank
Services

Billing Code

The code used by a plan or 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 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.

Payment Arrangement
Indicator

An indication as to whether a reimbursement arrangement other
than a standard fee-for-service model (such as capitation or a
bundled payment arrangement) applies.

DATA ELEMENT

DESCRIPTION

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 code’s 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 Food and
Drug Administration (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 of 3,199 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.