Federal Transparency in Coverage Final Rule
The Transparency in Coverage Final Rule, issued by the Centers for Medicare and Medicaid Services (CMS), requires health insurers to disclose pricing for covered services and items. Insurers must include the rates they have negotiated with participating providers for all covered services and items, as well as the allowed and billed amounts for out-of-network providers. Allowed amounts are the maximum rates insurers will pay for a given service and billed amounts are what providers have actually charged.
Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. Beginning July 2022, most group health plans and issuers of group or individual health insurance will begin posting pricing information for covered items and services. This pricing information can be used by third parties, such as researchers and app developers to help consumers better understand the costs associated with their health care.
Both Highmark and UPMC have established websites that will house the two (2) Machine Readable Files (MRFs). The links below leads to the machine-readable files that are made available in response to the Federal Transparency in Coverage Rule, and includes negotiated service rates and out-of-network allowed amounts between health plans and healthcare providers.
Highmark Website – https://mrfdata.hmhs.com
UPMC Website – https://www.upmchealthplan.com/transparency-in-coverage/mrf/