Transparency in Coverage Rule
For self-funded groups:
At this time, Blue Cross NC’s expectation is that Blue Cross NC will create, update, and make the Files publicly available for self-funded groups at the URL link below. The group will make the URL link to the Files available on its publicly accessible website to meet the requirements for group health plans. Blue Cross NC is in the process of updating its Administrative Services Agreement to clarify the nature of the responsibilities relevant to the Transparency in Coverage requirements. Customers should discuss any concerns and the requirements with their own legal counsel.
Excerpt from BCBSNC Website:
The Departments of the Treasury, Labor, and Health and Human Services (the Departments) issued the Transparency in Coverage Final Rules (85 FR 72158) on November 12, 2020. The final rules, requiring payers to publish machine-readable files containing in-network and out-of-network rates for providers in North Carolina and other states, went into effect for non-grandfathered group health plans and health insurance issuers in the individual and group markets (plans and issuers) on July 1, 2022.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to consumer transparency and agrees that transparency can help consumers. In compliance with the federal Transparency in Coverage rule enforcement deadline, Blue Cross NC published machine-readable files on July 1, 2022.
The requirement to provide machine-readable files is not a consumer-friendly solution and will not help people better understand the cost of their health care services.
The machine-readable files are intended for use by health care application developers to create tools and databases that will assist consumers in understanding health care costs across providers and health plan issuers.
Understanding the Data Included in the Machine-Readable Files
Machine-readable files published by Blue Cross NC conform to the technical implementation guide and schema version 1.0.0 published by CMS at https://github.com/CMSgov/price-transparency-guide.
The machine-readable files do:
- Include information on the rate insurers have negotiated with in-network providers for all covered items and services.
- Have a significant amount of data (estimated at 1 Terabyte per file), making it difficult to download using an average system or wireless connection.
The machine-readable files do NOT:
- Include meaningful information, such as an estimate of the cost members will be responsible for paying for an item or service. Individual costs vary depending upon the terms of the individual’s specific health insurance coverage or reimbursement arrangement.
- Guarantee payment and may not always reflect amounts on final claim processing documentation. Eligibility and benefit determinations are made when the claim is processed by Blue Cross NC.
- Pricing included in the fee schedule data is accurate as of the date it is pulled from system files and may be subject to change between the date the pricing data is pulled and the next update of the files.
- Rates for codes appearing in the file may vary when a given code rate has a modifier applied or when member benefit or treatment characteristics result in certain rate adjustments.
- Different code rates for the same codes may indicate that a modifier or some other type of member benefit or treatment characteristic applies.
- Billing codes that are not included in fee schedule data for in-network rates are not included in the file.
Blue Cross NC has an online tool designed specifically for consumers that includes cost estimates for the entire episode of care. Beyond what is available publicly, Blue Cross NC customers can use the tool to access specific, transparent pricing information based on their individual plans. This allows customers to see what they will pay for a procedure and compare prices by location and provider, so they can make informed health care decisions.
Price transparency can add significant value, but more action is needed to make quality, equitable health care more affordable. That is why we stay focused on developing and building on existing tools, like our cost estimator tool, to improve access to quality care, lower costs and provide members with meaningful information so they can make the best choices for their health care.
For member-specific benefit information, view our Transparency of Coverage information.