Payer MRF Requirements

As of July 1, 2022, Plans and Insurers (aka “payers) are mandated to publish two free and publicly accessible, online machine-readable files (MRFs) using this precise format. Payer MRF requirements include prices for all providers/care locations (e.g. imaging center, primary care clinic, ambulatory surgery center, professional rates, etc.), not just hospitals. To maintain compliance, these files must be updated monthly. 

Mandated Files

Certain plans and insurers (again, we usually refer to this group as “payers”) are mandated by the Transparency In Coverage Final Rule (TiC) to disclose their rates. 

Payers must post two files. Here is every rate type mandated by TiC:

In-Network File:

Description: Information for In-Network plans and insurers

• HIOS ID or EIN if no HIOS ID
• Billing Code*
• Place of Service Code, TIN & NPI
• In-Network Applicable Amounts

Details:
– Applicable amounts may be negotiated rates, fee schedule amounts, or derived amounts
– Bundled rates included

Allowed Amounts File:

Description: Info for Out-of-Network plans and insurers

• HIOS ID or EIN if no HIOS ID
• Billing Code*
• Place of Service Code, TIN & NPI
• Unique Allowed Amounts
• Historical Billed Charges

Details:
– Unique allowed amounts are amounts plan or issuer will likely contribute to the costs of items or services obtained from out-of-network providers
– Historical billed charges calculated based on 90-day lookback period beginning 180 days before file publication date
– Only out-of-network providers with >20 claims are included

*Billing Code: DRG, CPT, HCPCS, NDC, or other common identifier such as revenue code