Transparency in Coverage
Machine Readable Files
Machine-readable files are a requirement of the Transparency in Coverage Final Rule.
Health insurers are required to publicly display certain health care price information via machine-readable files on their websites beginning in 2022. These machine-readable files will include negotiated rates with in-network providers, allowed amounts for out-of-network providers and may include prescription-drug pricing.
CMS requires that machine-readable files (MRF) be posted in the JSON format; specifications are provided at https://github.com/CMSgov/price-transparency-guide.
The intended users of MRFs are researchers, regulators, and application developers. MRFs are not intended for member or consumer use. In 2023 members should have access to a user-friendly cost calculator tool with pricing information for 500 "shoppable services", as defined by CMS.
Price Transparency information may not be fully complete at this time. We are actively working to supplement file content.
If you have additional questions, please see the following sites for detailed information (each opens in a new window):
Amounts presented in the Machine Readable files are general, not member-specific or user-specific, per CMS Requirements. They don't include provider taxes, claim edits, deductibles, co-pays and out of pocket maximums which would be applied to a specific member.
Some services described in the Machine Readable files may not be available to everyone due to medical necessity or other restrictions. They are subject to "prerequisites to coverage," that is, conditions such as prior authorization may be needed before the service can be provided.
Medica is using the CMS File Schema (currently V1.1.0) which provides for reporting of negotiated rates at the product level, not the benefit plan level. Some services shown might not apply to all benefit plans within a product. If you need self-insured benefit plan information, please confirm with your Medica account representative the product under which your self-insured plan is included.
Medica works with partners including Leased Networks for some services. Medica does not have visibility to the contracts which our partners have with their providers and is depending partner information being complete and accurate based on our partners' good faith efforts. Medica doesn't have control over whether a given partner's provider is available at any given time.
Information is included for only the services that a provider or facility is licensed to furnish within their scope of service.
Any rates presented in the Machine Readable file for Diagnosis Related Groups (DRGs), also known as Medicare Severity Diagnosis Related Groups (MS-DRGs), All Patient Diagnosis Related Groups (APDRGs) and All Patient Refined Diagnosis Related Groups (APR-DRGs) are based on the current CMS standards. DRGs will vary case by case and patient by patient. In some situations, there are "outliers" to DRGs which may be significantly higher cost than what is shown in the files.
Medica doesn't imply alignment with pricing information furnished by any other payer and does not guarantee that its information to be a basis for comparison with other payers' Machine Readable file data.
Medica contracts using a "Percent of Billed Charges" submitted by providers. We are dependent on submitted claims to be able to determine these In Network Rates. Where providers have never submitted claims against a specific service for which the In Network Rate is a percent of billed charges, we have made a good faith effort to estimate the In Network Rate based on available information including but not limited to comparable rates from CMS and other sources.
If a provider bills a lower rate than what is allowed in the contract, including as a percent of charges, we include that lower rate in the In Network File in order to reflect the current state of the provider billing amounts.
Some Medica products include in network benefits in states outside Medica's usual service area. As applicable, we have included these rates for these services as part of our in network files.
For Allowed Amount (Out of Network) Files: COVID testing under state programs is currently covered by the state. There is no allowed amount paid by or billed to Medica. Therefore these items are not included.