Machine Readable Files

Transparency in Coverage

The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have issued the Transparency in Coverage final rules (85 FR 72158) on November 12, 2020. The final rules require non-grandfathered group health plans and health insurance issuers in the individual and group markets (plans and issuers) to disclose certain pricing information. Under the final rules a plan or issuer must disclose in-network negotiated rates and billed and out-of-network allowed through two machine-readable files posted on an internet website. 

Plans and issuers are required to make these files public for plan policy years beginning with 2022.  This material is for information only. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional.  

  • 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.  This file and the included pricing data is not a guarantee of 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. 
  • 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 codes 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.
  • Price transparency requirement can result in very large file sizes which may, in turn, cause issues while downloading them. If you are experiencing problems, please try a different web browser or check your Internet/Wi-Fi speed. 

 

Understanding the Data

Machine-readable files published by Blue Cross of NC confirm to the technical implementation guide and schema version 1.0.0 published by CMS at https://github.com/CMSgov/price-transparency-guide 

If you're looking for member-specific benefit information, view our Transparency of Coverage information