In October 2020, CMS issued the Transparency in Coverage final rule. As part of this rule, health plans were initially required to publish three machine-readable files (MRFs) by January 1, 2022:
- In-Network Provider Negotiated Rates
- Out-of-Network Allowed Amounts
- Prescription drug pricing
CMS deferred enforcement of Prescription drug pricing until further rulemaking. Enforcement for the other two MRFs was delayed for six months until July 1, 2022, allowing CMS additional time for schema discussions.
On March 1, 2022 — 18 months after the final rule was issued — CMS set v1.0.0, known as the “enforcement data schema.” Getting to the final data schema was a tedious process. Twenty other versions were created before the final schema was set. And additional CMS fine tuning is expected this year and beyond. In this blog, Claritev explores what happened on the road to getting to the final schema.
Getting to v1.0.0
To facilitate health plans’ compliance with the MRF requirement and to foster an iterative, transparent, and communal development process, CMS used a collaborative platform called GitHub to post draft schema versions for public consideration and feedback. In the first quarter of 2021, GitHub members began posting schema questions. Those questions and discussions led to several schema changes during the second quarter of 2021. On September 1, 2021, CMS released the first “committed” schema, v0.1, but refinements continued through the remainder of 2021 and into 2022.
Concerns over file size, especially for the in-network rate file, fueled some of the changes to the schema. To address the issue, CMS introduced and discussed optimization approaches. One example is the service code attribute. CMS realized a lot of duplicated data would be created because multiple service code locations would have the same negotiated rates. To address this, the data field for service codes was moved to a new object and changed from a single string to an array of strings.
Challenges to creating MRFs
Even with the final schema published, ongoing efforts to address file size concerns have created challenges for health plans and companies like Claritev working to create the MRFs. This has led to continued changes, including some significant changes published within a couple weeks of the final schema’s release. For example, early schema versions required each provider group to be reported with each negotiated rate for each item in service. This requirement created an unmanageable amount of duplicative data, especially when considering the scope of a provider network like Claritev’s that includes over one million providers. After publishing the final schema, CMS revised guidance, allowing the use of URLs that point to provider groups applicable to the negotiated rates. In other words, the provider group can now be in its own file, which helps to significantly reduce the size of In-Network MRFs.
While changes in guidance like this are helpful, they make it difficult to meet the publication timelines because they require revisions to logic already created. For example, at a webinar on March 16, 2022, CMS announced a late change to the v1.0.0 schema for In-Network MRFs. The “negotiated_type” field definition was expanded to include “percentage” and “per diem.” This change impacts how Claritev will handle UB data.
Future changes to the MRF schema
Although CMS committed v1.0.0, the “enforcement data schema” on March 1, 2022, as of April 29, 2022, the schema has evolved to v.1.0.8.1
CMS will likely continue to refine the data schema as necessary. Automatic notification of changes are not available, but CMS has indicated enforcement schema updates will be addressed in future webinars. Claritev will attend the webinars so that we remain knowledgeable about schema changes, and what they mean for us and our clients.
For more information on how Claritev can help you address Transparency in Coverage rule, contact us .
1 Changes in the last number indicate minor revisions by CMS.
