Compliance
Transparency in Coverage
Required federal disclosures on in-network and out-of-network pricing, published as machine-readable files and updated monthly.
Machine-readable files (MRF)
The Departments of the Treasury, Labor, and Health and Human Services issued the Transparency in Coverage final rules (85 FR 72158) on November 12, 2020. The rules require non-grandfathered group health plans and health insurance issuers to disclose in-network negotiated rates and out-of-network allowed amounts through machine-readable files posted on a public website, for plan policy years beginning in 2022 and later. Files are updated monthly.
- Cigna PPO Network MRF
- Employers Health Network (EHN) MRF
- Evolutions Healthcare Systems (EHS) MRF
- MultiPlan Out of Network Negotiation Services MRF
- MultiPlan Network, Beech Street, IHP MRF
- MultiPlan Practitioner & Ancillary MRF
- PHCS Network MRF
- PHCS Practitioner & Ancillary MRF
- PrimeHealth Network MRF
Plans based on Reference-Based Pricing: Reference-Based Pricing plans do not negotiate pricing with providers. Instead, the plan pays a percentage over Medicare rates — typically 120%–140%, though this may be adjusted as needed. Medicare rates can be found at cms.gov. Rates may be influenced by modifiers, geographic location, and changes to Medicare rates.
This material is for informational purposes only, is subject to change, and does not guarantee eligibility or coverage. Call 1 (800) 845-7629 for questions about coverage and member responsibility.
Rates for codes appearing in the files may vary when a modifier applies or when member benefit or treatment characteristics result in rate adjustments. Different rates for the same code may indicate a modifier or other benefit/treatment characteristic applies. Pricing is accurate as of the date it is pulled from system files and may change before the next monthly update. This data is not a guarantee of payment and may not reflect final claim processing. Eligibility and benefit determinations are made when a claim is processed by Anchor Benefit Consulting, Inc.
Because price transparency files can be very large, you may encounter issues downloading them. If so, try a different browser or check your internet connection speed. Some files are in JSON format and may be as large as 1 TB — ensure your hardware and software can handle a file of that size before attempting to download. These files are formatted to allow researchers, regulators, and application developers to access and analyze the data.
Understanding the data: These machine-readable files adhere to the technical implementation guide and schema version 1.0.0 published by CMS at github.com/CMSgov/price-transparency-guide.