As part of the Transparency in Coverage Final Rule set forth by the U.S. Department of the Treasury, the U.S. Department of Labor, and the U.S. Department of Health and Human Services (referred to collectively as the “Tri-Agencies”), group health plans and health insurance issuers are required to make available to the public negotiated rates for all covered items with in-network providers, and historical payments to and billed charges from, out-of-network providers through machine-readable files (MRFs) posted on an internet website, updated monthly. Prodegi is independent third party administrator (TPA) of self funded health plans specializing in professional claims administration, benefit customization, cost-control, health management and technological tools for our clients and members. Our clients, who are Plan Sponsors, contract with regional and national Preferred Provider Organization (PPOs) and Pharmacy Benefit Managers (PBMs) for discounted rates with hospitals, doctors, clinics and pharmacies. We have created this portal as a service to those Plan Sponsors to host the machine readable files that Plan Sponsors are required to publicly provide to facilitate the transparency in coverage rule as mandated by federal law. The files provided here contain in-network negotiated payment rates and historical out-of-network charges for covered items and services, including prescription drugs in machine readable file formats as required by CMS-9915F.
To ensure data integrity, all files must conform to a non-proprietary, open standard format, like JSON, XML or YAML, and be made available via HTTPS. The content of the files is formatted to technical standards in guidance published by the Centers for Medicare & Medicaid Services (CMS). In most cases, these files are provided by the PPOs and PBMs in the CMS sample file formats.
The machine-readable files are independently generated by PPOs and PBMs who negotiate and manage these contracted rates on behalf of Plan Sponsors. From the “View Network List” link below you can choose the PPO network for which you wish to access machine readable files.
The machine-readable files will permit the public to have access to health plan payment information that can be used to understand health plan pricing and the cost for health care services.The files that are posted will include:- In-Network Rate File: rates for all covered items and services between the plan or issuer and in-network providers.- Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.
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