BCBSTX Transparency in
Coverage Machine Readable
Files Implementation Guide for
ASO Accounts

Version 2.1
1/11/2023

Table of Contents
1

Overview ......................................................................................... 3

1.1
1.2
1.3

M ACHINE READABLE FILE (MRF) OVERVIEW................................................................ 3
ABOUT THIS DOCUMENT............................................................................................... 3
CONTACT INFORMATION ............................................................................................... 3

2

Accessing the Machine Readable Files ........................................ 3

2.1
2.2

NAVIGATION ................................................................................................................. 4
TABLE OF CONTENTS FILE NAMING CONVENTION ......................................................... 5

2.3
2.4
2.5
2.6

ACCESSING THE FILES....................................................................................................... 5
FILES AVAILABLE.......................................................................................................... 5
PUBLICATION TIMING .................................................................................................... 6
MRF USAGE CONSIDERATIONS .................................................................................... 6

3

Machine Readable Files Details and Data Elements .................... 7

3.1

TABLE OF CONTENTS FILE ............................................................................................ 7

3.1.1 Plan Name Variations ......................................................................................................... 9

3.2
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.5.1
3.2.5.2

IN-NETWORK FILE ...................................................................................................... 10
Negotiated Rates Details (FFS) ............................................................................13
Negotiated Arrangement/Type Assignments ...........................................................14
Standard Pricing Methods Table...........................................................................15
Individual Consideration and Manual Pay ...............................................................16
Covered Services Details for Capitation .................................................................17
Negotiated Rates Object for Capitated Rates ..........................................................18
Covered Services Object for Capitated Rates .........................................................19

3.3

OUT-OF-NETWORK ALLOWED AMOUNT FILE ............................................................... 20

3.3.1
3.3.2

Out-Of -Network Allowed Amount File Data Elements ...............................................20
Patient Privacy Requirement for Out of Network ......................................................22

3.4
3.5

BILLING CODE TYPES ................................................................................................. 23
PLACE OF SERVICE CODES ........................................................................................ 23

4

Data Retention .............................................................................. 25

5

Definitions..................................................................................... 25

Appendix................................................................................................ 28
6.1

Checking your downloaded machine-readable file for integrity ...................................28

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1

Overview

1.1

Machine Readable File (MRF) Overview

Under the Transparency in Coverage Final Rule, plans and issuers will disclose pricing information to the
public through machine readable files accessible via a table of contents file. One file requires disclosureof negotiated rates between plans and providers for covered items and services, known as the In-Network
File. The second file discloses unique allowed amounts and billed charges for out of network services,known as the Out-of-Network Allowed Amount File. The table of contents includes links to both types off iles. The machine readable files are posted on a publicly accessible website, free of charge, without
requiring personal identifying information or logging into an account. The f ile is updated monthly. The f iles
are described in detail in Section 3 of this document. A third file related to pharmacy is indefinitely on
hold. The f ile contents also include coverage options subject to the Texas Health Care Reimbursement
Rate Inf ormation pursuant to Chapter 38 of the Texas Insurance Code.
A machine readable file is a digital representation of information in a f ile that can be imported or read by acomputer system for further processing without human intervention, while ensuring no semantic meaning
is lost. The machine readable file exchange uses the JavaScript Object Notation (JSON) file format andleverage CMS schema version 0.10 as defined on the CMS GitHub site.
Group health plans are accountable for publishing the pricing for their plans. To support group healthplans that leverage BCBSTX for network negotiation and claims processing, BCBSTX will generate the In
Network and Out of Network Files for all plans administered by BCBSTX and required to comply with theTransparency in Coverage Final Rule. These files are available to the issuer of a group health plan on
July 1, 2022.

1.2

About This Document

The MRF Implementation Guide supports Accounts with Administrated Services Only (ASO) byintroducing the file requirements specified under the Transparency in Coverage Rule, defining the data
included in the files, and clarifying the process for accessing the specific files with pricing data byaccount’s benefit plans.
This implementation guide includes:• Directions for assessing the machine readable files (Section 2)• Def inition of the Table of Contents file (section 2.2)
• Clarif ication on publication timing and data updates (Section 2.4)
• Def inition of the In-Network File data layout with field definitions (Section 3.3)
• Def inition of the Out-of-Network Allowed Amount File data layout with field definitions (Section
3.4)

1.3

Contact Information

For questions related to the implementation guide or machine readable files please contact
MRFInquiry@BCBSTX.com.
For all other questions, please reach out your account representative.

2

Accessing the Machine Readable Files

BCBSTX publishes each account’s files to a publicly accessible site. The site includes the MRFs for allplans offered by the account that have active membership and are administered by BCBSTX.

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2.1

Navigation

To access the files, each account has a unique link to a webpage driven by the company’s Employer
Identif ication Number (EIN). This webpage is freely available without logging in to an account and can beaccessed using the following format:
https://bcbstx.com/asomrf?EIN=123456789
Navigating to the website:
1) Replace [123456789] with the organization’s EIN removing the “- “
a. Ex: 12-3456789 is the original EIN; add 123456789 in the URL
2) Type the URL to a browser and hit enter. The screen will now display access to the files
specific to the organization’s account, representing all plans with active membership.
These f iles are compressed using .gzip format, which may require a tool for opening.
Screen Preview:
Below is a screenshot of the landing page and Table of Contents that includes an account’s MRFs. The
Last Updated On date represents the date the Table of Contents MRF was created. The INN and OON
MRFs may not reflect the same date as the Last Updated On date on the webpage.

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2.2

Table of Contents File Naming Convention

The table of contents includes a downloadable page which is used to access the MRFs. The link uses thef ollowing naming conventions:<YYYY-MM-DD>_<payer or issuer name>_<EIN>_index.<file extension>
Example: 2021-06-25_Blue Cross and Blue Shield of Texas_123456789_index.json
Component Definitions:•<YYYY-MM-DD>: The date that the file was generated with updated plan (or policy) information
which will be 25th of before each month•<payer or issuer name>: The name of the payer or issuer organization•<EIN>: Ref erences the account’s specific EIN used to render the plan (or policy) information•<f ile extension>: Defines the file extension as JSON

2.3

Accessing the files
1) Click on download button next to the table of contents ‘index’. This will launch a popup window.
2) Click “download’ on the pop up window to initiate the file download. Once the file is downloaded
and opened, the table of contents will show as the sample below:

3) These f iles are in native json format as one line of information, you may need to open the fileusing a f ormatting tool such as Notepad++, or upload to a json beautifier tool on the internet, inorder to read the structure of the file.

4) Depending on the application used to open the table of contents, you may need to copy andpaste the machine readable files into your browser. These files are compressed using the .gzip
f ormat, which may require a tool to open.
5) Note that once the machine-readable file is downloaded, users may validate the integrity of thedownloaded file by using the hash code. Please see the Appendix for more information.

2.4

Files Available

As described, the In-Network file and the Out-of-Network File is published to the public site available in

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)5

the Table of Contents file. The In-Network File discloses negotiated rates between plans and providers
f or all covered items and services. The Out-of-Network Allowed Amount File discloses unique allowableamounts paid for out-of-network services as well as the associated billed charges during a specified time
period. Both are available via a separate link in the table of contents.
Sample machine readable files:
In Network machine readable file
Out of Network machine readable file

2.5

Publication Timing

As of July 1, 2022, BCBSTX publishes the machine-readable files on the 25th before the 1st of each month
beginning on the plan’s effective date.
Table of Contents Publication Dates:• Example 1: A plan coverage with a renewal date of Jan. 1, 2022 – July 1, 2022, is first publishedon June 25, 2022, when the rule goes into effect.
• Example 2: A plan coverage with a renewal date of July 2, 2022, or later, and renews on the 1st
day of the month is first published on the 25th before the month in which the plan renews.
• Example 3: A new plan coverage is first published on the 25th before the effective date’s month.

The out-of-network file will only include out-of-network data once the plan has enough claims to meet thethreshold for publication, and after the lookback period of 180 days with a 90-day run-out has beenreached to support the publication of the data.
• Example 1: A plan coverage with a plan year beginning Jan. 1, 2022, or Feb. 1, 2022, withqualif ying claims will have out-of-network data published in the initial file released on June 25,
2022.
• Example 2: A plan with a July 1, 2022, renewal date will not have met the lookback period of 180
days with a 90-day run-out for qualifying claims and, therefore, the out-of-network file publishedwill contain no data. The November 1, 2022, update will be the first month where qualifying out of -network claims will be incorporated into the out-of-network file.
Out-of -network pricing will not be reported for any new plan until at least 4 months following the effective
date of the plan.
In-network and out-of-network pricing files will be removed from the site the month following the plan
termination date.

2.6

MRF Usage Considerations

Af ter accessing the MRFs, the ASO accounts may choose how to share the information with theirmembers. Two potential options include publishing a direct link to this site or downloading and hosting thef iles in an alternative location. Regardless of which option is chosen, there isn’t a limitation for file access.
The account will be able to access their files through the month until the next set of files are posted.
If ASO accounts are not linking to BCBSTX but are instead downloading and publishing the files
themselves, they will need to update the Entity Type field from “third-party administrator” to “healthinsurance issuer” or something similar before publishing.

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3

Machine Readable Files Details and Data Elements

This section describes the key components of the Table of Contents, In-Network and Out-of-Network
Machine Readable Files according to the Transparency in Coverage Final Rule.
Key Components Content Descriptions
Table of Contents – includes links to the In-Network and Out-of-Network Files for ease of access.
In-Network File – available pricing rates known to be in effect at the date of production curated frommultiple pricing data sources and/or contracts.
Out-of-Network File – allowed and billed charge amounts based on actual claims received for out-ofnetwork services on the 90-day period that begins 180 days prior to the file publication date. These files
may not have pricing information if there were no qualifying samples of out of network claims to publish.

3.1

Table of Contents File

The table of contents file provides access to the in-network and out-of-network files. For national plans,
there are separate files to represent all the plans for that state, as this will make files more manageablef or downloading.
The table below defines each data field and if they are required for the Table of Contents File.

Definition of Table of Contents Data Fields and Disclosures
Data Element

CMS Definition

Default Value“Blue Cross and Blue
Shield of <State>”

Entity Name

The legal name of theentity publishing the MRF

Entity TypeThe organization type
publishing the file such as agroup health plan, healthinsurance issuer, or a third
party contracted through the “third-party
plan or issuer to provide the administrator”
required information (e.g., athird-party administrator, ahealth care claims
clearinghouse, or a healthinsurance issuer that hascontracted with a group healthplan sponsor)

Plan Name

The plan name and name of<group #> <benefit
plan sponsor and/or
agreement name>insurance company

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)

Added Disclosures
N/A

ASO accounts that decide to
download and publish their own
f iles will need to change thisf ield to “health insurance issuer”

PPO plans - Example: if thegroup # is “12345” and thebenef it agreement name is “SWHCN OPT 1”, the Plan Namef ield would show “12345 SW
HCN OPT 1”

7

HMO Plans - there may be
additional identifiers appended
to this name, such as group andsection numbers to differentiate
when there is more than one
capitation table per account /benef it agreement. Example:“12345 SW HCN OPT
1_123456_0001”
See section 3.1.1 for all
possible plan name variations.
For ASO accounts, the file willcontain “EIN” only, not the
Health Insurance Oversight
System (HIOS)

Plan Id Type

Allowed values: "EIN" and"HIOS"

Plan ID

The plan ID is the 10-digit
HIOS identifier, or, if
unavailable, the 5-digit HIOS <Employer ID Number>
EINs are reported without theidentifier. For ASO’s or when
hyphen – Example: 12-3456789
the HIOS identifier iswill render as “123456789”
unavailable, the Plan ID is the Example: XXXXXXXXX
EIN f or each plan or coverageof fered by a plan or issuer

Market Type

Allowed values: "group" and“group”"individual"

In-Network
File(s)See Section 3.2

Allowed Amount(Out-of-Network) See Section 3.3
File(s)“EIN”

ASO f iles only reporting group
market types

The table of contents fileprovides the links to all the InDescriptions and URLs Network pricing plan files
associated with each benefit
for INN MRFs
plan/agreement and domainname f or downloading the innetwork data
The table of contents fileprovides the links to all theallowed amount pricing planf iles associated with eachbenef it plan/agreement. For
each allowed amount file, there
is a description and location(domain name where the out-ofDescriptions and URLs
network data can be
for OON MRFs
downloaded).
Some plans may not have outof -network benefits or enoughclaims to qualify for publicationand theref ore no pricing data
will be published in the

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)

8

downloadable out-of-network
machine readable files.

3.1.1 Plan Name Variations
Plan TypeHow Plan Name is Created

Input Data

Plan Name Published inTable of Contents

PPO

Plan name is created by
combining the Group # andBenef it Agreement Description
separated by a spaceGroup #: 123456

123456 PPO Plan

HMO (MT, OK,
NM, and TX
not Blue
Essentials)

Plan name is created by
combining the Group # andBenef it Agreement Description
separated by a spaceGroup #: 234567

HMO (TX Blue
Essentials)

Plan name is created by
combining the Account # andBenef it Agreement Description
separated by a space andappending the Group # andSection # separated by anunderscore

Account #: 123456

Plan name is created by
combining the Group # andBenef it Agreement Description
separated by a space andappending the benefit plan #and product type code
separated by an underscore

Group #: 456789

Plan name is created by
combining the Group # andBenef it Agreement Description
separated by a space andappending the alpha prefix
separated by an underscore

Group #: 567890

HMO (IL)

PPO with MoreThan One
Alpha Prefix

Benef it Agreement
Description: PPO Plan

Benef it Agreement
Description: HMO Plan

Benef it Agreement
Description: Blue
Essentials HMO

123456 Blue Essentials
HMO_987654_0001

Group Number: 987654
Section Number: 0001

Benef it Agreement
Description: IL HMO
Plan

456789 IL HMO
Plan_A01_BLUEH

Benef it Plan #: A01
Product Type Code:
BLUEH
Benef it Agreement
Description: PPO Plan
Alpha Prefix (1 of 2):
VNU
Alpha Prefix (2 of 2):
XOF

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)

234567 HMO Plan

Plan Name f or Alpha
Pref ix 1: 567890 PPO
Plan_VNU
Plan Name f or Alpha
Pref ix 2: 567890 PPO
Plan_XOF

93.2

In-Network FileThe In-Network MRF f or the Transparency in Coverage Final Ruling includes the following naming
convention:<YYYY-MM-DD>_<payer or issuer name>_<network name>_<file type name>.<file extens ion>
Variations:
In-Network MRF

Naming Convention

INN VBC MRF (TX Sanitas)<YYYY-MM-DD>_Blue-Cross-and-Blue-Shield-ofTexas_MyBlue-Health-HMO-TX-Sanitas-capitation-rate_innetwork-rates.json

INN VBC MRF (TX Kelsey)<YYYY-MM-DD>_Blue-Cross-and-Blue-Shield-of-Texas_BlueEssentials-TX-Kelsey-Cap-Table-<#>_in-network-rates.json<YYYY-MM-DD>_Blue-Cross-and-Blue-Shield-of- Illinois_<network name>-<product type code>-<benefit plan number>IL-HMO-Non-Standard_in-network-rates.JSONINN VBC MRF (IL Non-Standard
Medical Groups)
INN VBC MRF (IL Standard &Advocate Medical Groups)<YYYY-MM-DD>_Blue-Cross-and-Blue-Shield-of- Illinois_<network name>-<product type code>-<benefit plan number>-ILHMO-Standard-Advocate-Health_in-network-rates.JSON

National Network INN MRFs

<YYYY-MM-DD><individual (geo area) plan code><network
id>_in-network-rates_N_of_N.json

INN Common MRF

YYYY-MM-DD_<payer or issuer name>_<member network
name>_common_<file type name>.file extension

INN Custom MRF

YYYY-MM-DD_<payer or issuer name>_<member network
name>-<group number>_<file type name>.file extension

Note: The f ile reports other health plan issuers’ In-Network MRFs for networks that aren’t managed by
BCBSTX. Other health plan issuers’ interpretation of the Transparency in Coverage Final Ruling may
dif fer.
The data elements incorporated in the In-Network File are outlined below.

In-Network File Data Elements
Data Element
Entity Name

Entity TypeCMS Definition

Default Value

Added Disclosures

The legal name of the entity “Blue Cross and Blue Shield
N/A
publishing the machineof <State>”readable f ile
In-network machine
The type of entity that is“health insurance issuer”
readable f ile is available topublishing the machineboth ASO and non-ASO
readable f ile (a group healthplans, therefore, BCBSTX isplan, health insurance

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)

10

populating as “healthinsurance issuer”

issuer, or a third party withwhich the plan or issuer has
contracted to provide therequired information, such asa third-party administrator, ahealth care claims
clearinghouse, or a healthinsurance issuer that hascontracted with a grouphealth plan sponsor).
<YYYY-MM-DD>
The date in which the f ile
Last Updated On was last updated. Date must
be in an ISO 8601 f ormat
VersionThe version of the schemaf or the produce information

Negotiation
Arrangement

An indication as to whether areimbursement arrangement
other than a standard feef or-service model applies.
Allowed values: "ffs,""bundle" or "capitation"
CMS-maintained two-digit
codes available on CMS’
websitePlace of Service
Code“1.3.1”

Represents the day of the
f ile generation
This could change as new
CMS schema updates are
released"f fs", "bundle" or "capitation" Varies based on
pricing/negotiating method
used
See Section 3.2.2 for moredetails
Possible Values: 02, 10, 11, The CMS place-of-service
17, 18, 19, 20, 22, 23, 24, codes associated with the49, 62, 66, 72, 81
negotiated rate site ofservice
Place of Service Codes will
only be populated for“prof essional” providers

Billing code

Billing code
nameBilling CodeDescription

Billing Code

Code used by a Plan, Issuer, The corresponding billingor health care provider tocode
identify health care items orservices for purposes ofbilling, adjudicating, andpaying claims for a covered
item or service

In-network machinereadable f ile will only
include CPT, HCPC, DRG,
or Revenue Code billing
codes.

This is name of theitem/service that is offered

The billing code standard
short form description

This will be the short form
description, if there is no
short f orm description,
BCBSTX will use the longf orm description in its place.

Brief description of theitem/service

The billing code standard
long form description

This will be the long form
description, if there is nolong f orm description,
BCBSTX will use the shortf orm description in its place.

Common billing code types The billing code type

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)

See section 3.4

11

Type

Billing CodeType Version

reporting value for CPT,
HCPC, DRG, or Revenue
Codes.
There might be versions
associated with the billingcode typeThe billing code typeversion.

N/A

This object is used when a N/Aprovider payment model
where covered items and
Negotiated Rates services provided to a
(FFS)participant or beneficiary fora specific treatment orprocedure are paid
separately.

See section 3.2.1

This object is used when a N/A
payment model under whicha provider is paid a single
Bundled Codes payment for all covered
items and services provided
to a participant or beneficiaryf or a specific treatment orprocedure.

BCBSTX does not contract
with providers for bundledservices. However, otherBlue Cross and Blue Shieldplan af filiates may include
bundled payments innational pricing files

This object is used when a N/A
payment of a fixed fee
per participant or
benef iciary per unit of time inadvance to the provider f or
the delivery of a covered
treatment or procedure.

See section 3.2.5

Covered ServicesCapitation rates can change
based on a member’s age
and / or gender. The
Capitation rate disclosed in
the f ile is reflective of thebase capitation
rate applicable to a plan andmay not represent thecapitation rate for individual
policies.

NPI

TIN Type

An array of individual (type 1 The providers National
If a provider does not have& 2) provider identification Provider Identifier (NPI)
an NPI, BCBSTX uses “0”numbers (NPI)
associated with the Tax
Both type 1 and 2 NPIs are
Identification Number (TIN)
populated in the NPI field toand negotiated rateensure both elements arecaptured within the schema
Contains tax information on “EIN”
the place of business

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)

“NPI” is used if a provider
uses their Social Security
Number as their TIN

12

TIN Value

Either the unique Tax<Tax ID Number>
Identif ication Number issued
Example: XXXXXXXXX
by the Internal Revenue
Service (IRS) f or type "EIN"or the provider's NPI for TIN
type "NPI"

NPI is used again if aprovider uses their social
security number as theirTIN.

The unique, primary key for <XXX-XX>
the associated provider
group object

The Provider Group ID will
be preceded by a 3-digit
home plan code (a uniquecode assigned to eachhealth plan contracted with
the BCBS Association).
Example: 121 for IL, 250 f orMT, 340 f or OK, 290 for
NM, and 400 f or TX

The additional information N/Atext f ield can be used toprovide context fornegotiated arrangementsthat do not fit the existing
schema f ormat. Please open
a Github discussion to ask aquestion about your situation
if you plan to use this
attribute.

Not populating this field as it
is optional

Provider GroupID

Additional
Information

See CMS GitHub for detailed file schema and examples.

3.2.1

Negotiated Rates Details (FFS)
Negotiated Rates

Data Element
Negotiated Type

Negotiated Rate

Expiration Date

CMS Definition
There are a f ew ways inwhich negotiated rates
can happen. Allowed
values: "negotiated,""derived," and "feeschedule."

Default Value

Added Disclosures"negotiated," "derived," "fee See section 3.2.2
schedule", “percentage”, or“per diem” based on thepricing/negotiation methodused

The percentage or dollar <X.XX>
amount based on thenegotiation typeSee Section 3.2.1

The date in which the<YYYY-MM-DD>
agreement f or thenegotiated price based on
the negotiated type ends.
Date must be in an ISO
8601 f ormat“9999-12-31” is used if there
is no end date.

ASO MRF IMPLEMENT ATION GUIDE ( V 2.1)

The date used represents
the earliest of these four
possible dates: rate
expiration date,reimbursement schedule
date, PIN group expiration13

date, and the network
expiration date

Place of Service
Code

The CMS-maintained two-<XX>
digit code that is placedon a professional claim to
indicate the setting inwhich a service wasprovided. When attributeof billing class has thevalue of "professional,"
service code is required.

The CMS place of service
codes associated with thenegotiated rate site ofservice
Place of Service Codes will
only be populated for“prof essional” providers
See table 3.5 f or thecomplete list

Allowed values:"professional,""institutional"“prof essional” or“institutional”

Billing Class“Prof essional” is used whenreporting rates forprof essionals (individual
providers, medical groups,etc.) and “institutional” whenreporting rates for f acilities(hospitals, etc.)
Note: Providers who bill on
UB-04s will be populated as“institutional” and providers
who bill on CMS/HCFA
1500s will be populated as“prof essional”

An array of strings. There N/A
are certain billing code
types that allow for
modifiers (e.g., the CPT
coding type allows formodifiers). If a negotiatedrate f or a billing code typeis dependent on a modifier
f or the reported item orservice, then an additional
negotiated price object
should be included torepresent the difference.

Billing Code
Modifier

3.2.2

Not reporting on or
populating rates based on
the billing code modifier

Negotiated Arrangement/Type Assignments

Pricing methods must adhere to the terms of provider contracting and plan-adopted medical policy andapplicable state laws/regulations. The method could be different across providers and regions.

Arrangement/Type
Derived amountDefinition
Price that a group health plan or health insurance issuer assigns to an

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14

item or service for the purpose of internal accounting, reconciliation with
providers, or submitting data as a ($) dollar amount in accordance with
the Transparency in Coverage Final Rule requirements.

Underlying Fee Schedule

Rate f or a covered item or service from a particular in-network provider
or providers that a group health plan or health insurance issuer uses todetermine a participant’s or beneficiary’s cost-sharing liability for theitem or service, when that rate is different from the negotiated rate orderived amount.

NegotiatedRef lected as a dollar amount, for each covered item or service under
the plan or coverage that the plan or issuer has contractually agreed to
pay an in-network provider, except for prescription drugs that are
subject to a fee-for-service reimbursement arrangement, which must bereported in the prescription drug machine readable file. If the negotiatedrate is subject to change based upon participant, beneficiary, or
enrollee-specific characteristics, these dollar amounts should be
ref lected as the base negotiated rate applicable to the item or service
prior to adjustments for participant, beneficiary, or enrollee-specificcharacteristics.

Percentage

The negotiated percentage value for a covered item or service from aparticular in-network provider for a percentage of billed charges
arrangement.

Per Diem

A daily rate, reflected as a dollar amount, for each covered item orservice under the plan or coverage that the plan or issuer has
contractually agrees to pay an in-network provider.

3.2.3

Standard Pricing Methods Table
Negotiated Type:Standard Pricing
Methods

DRG Weight Based

APG/ Procedure CodeGrouping

Percentage of Charge

NegotiatedArrangement:“negotiated”(For TX: Inlier DRG Fee f or service
TX) (f or IL: DRG(FFS)
weight-based rate)
payment for each
DRG Codenegotiated(f or OK: Multiple
APG’s could be on aclaim and are treatedas a single line claim)

FFS

negotiated

FFS

percentage

Pricing Approach“derived”
FFS, bundle,
or capitation “fee schedule”, “percentage” and“per diem”

Reporting apercentage of bill of
charge rate

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15

Calculated as 1 unit (1day) (f acility)

FFS

negotiatedCalculate based on apredetermined factor
Percentage of Medicare of locality based on
Medicare (OON TX
only)

FFS

negotiatedUse applicable percase rate

FFS

negotiatedFFS

per diem

FFS

negotiated

Per Unit

Prof essional can besystem calculated or
use EDW actual
allowed amountFFS

negotiatedDME

Use rental rate, if
there is no rental rate
use global/purchaserate (prof essional)

FFS

negotiatedAnesthesia

Assume 1 time unit
and no physical status
modifiers(prof essional)
See table 3.2.5

capitation

negotiated (TX/IL only)

Calculate based onclaims data (See
Section 3.2.4)

FFS

derivedIndividual consideration

Calculate based onclaims data (See
Section 3.2.4)

FFS

derivedManual Pay

3.2.4

Individual Consideration and Manual Pay

Per Unit

Per Case(f acility)
One day rate per code
set that triggers the
per diem (does notinclude stop loss)

Per Diem(f acility)

Capitation (VBC)

For providers with a percent of charge rate for an item/service, the appropriate negotiated rate is
calculated using claims data by:• Deriving negotiated rate based solely on claims experience• Retrieving all claim history for each service by using a lookback period of 6 months (180 days)
with a 3-month (90 day) runout of incurred claims• Removing outliers by using a standard deviation calculation• Excluding items and services that do not have at least 6 claims headers per network, billing code,provider, and site of service• Reporting the average rate based on claim history

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Note: Rates for items/services may not be published if they are not billed during the lookback period ormeet a 6-claim minimum to be reported.

3.2.5

Covered Services Details for Capitation

Capitation agreements are only in place in IL and TX. Files produced for MT, NM and OK will not be using
the covered services object.
Benef it plans that have providers in-network with capitation agreements will have at least two in-network
machine readable files – one machine readable file with FFS rates reported (see section 3.2.1) and one
or more machine readable file with capitation rates reported.
Capitated items/services are all covered under a single negotiated rate. The JSON schema only allows
f or the reporting of a single rate in the negotiated rate object and requires the reporting of all capitatedbilling codes in the covered services object, therefore, BCBSTX populates the other required fields in the
JSON schema for capitation. Outlined below is how BCBSTX is populating the fields for in-network
machine readable files with capitation rates.
If applicable, negotiated capitation may vary greatly based upon the methodology and the services
subject to the agreement. The base rate excludes financial incentives and other arrangements that aredone through reconciliation process. Agreements where some or all of these reconciliations do not occur
may look inconsistent with others that use a similar approach. Additionally, some value-based models will
include substantially more or less services under the capitation rate than other arrangements also leading
to variability.

Data Element

CMS Definition

Default Value

Added Disclosures

Negotiation
Arrangement

An indication as to whethera reimbursement
arrangement other than astandard fee-for-service
model applies. Allowed
values: "ffs," "bundle" or"capitation""capitation"

Only applies to innetwork machinereadable f iles withcapitation rates reported

Name

This is name of theitem/service that is offered“capitated”

Indicates the billing
codes are capitated andreported in the covered
services object

Billing Code Type

Common bill code types“LOCAL”

Allows for unique billingcode creation – definedon GitHub as “Local
Code Processing”

Billing Code Type
Version

There might be versions
associated with the billingcode type

Populate with thecurrent year

N/A

Billing Code

Code used by a Plan,
Issuer, or health care

“CAP”

Indicates billing code iscapitation

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provider to identify healthcare items or services forpurposes of billing,
adjudicating, and paying
claims for a covered item orservice
Description

Brief description of theitem/service

See covered
services object forcapitated billing
codes.

Directs the user to view
the actual billing codes in
the covered services
object. See 3.2.5.2

Negotiated Rates

This is an arrayof negotiated rate details
object types

N/A

BCBSTX reports thecapitation rate in thisobject. See 3.2.5.1

Covered Services

This is an array of covered
services objects. This array
contains all the different
codes in a capitation
arrangement
if capitation is selected
f or negotiation
arrangement.

N/A

BCBSTX reports thebilling codes covered
under the division of
f inancial responsibility(DOFR) in this object.
See 3.2.5.2

3.2.5.1

Negotiated Rates Object for Capitated Rates

Data Element

CMS Definition

Negotiated Type

There are a f ew ways inwhich negotiated rates canhappen. Allowed values:"negotiated," "derived," and"f ee schedule." Seeadditional notes.

Negotiated Rate

The dollar amount basedon the negotiation
type.

The base
capitation rate

Expiration Date

The date in which theagreement f or thenegotiatedprice based on
the negotiatedtype ends. Date must bein an ISO 8601 f ormat.

<YYYY-MM-DD>

Place of Service
Code

The CMS-maintained twodigit code that is placed ona prof essional claim to
indicate the setting in which
a service was provided.
When attribute of billingclass has the value of"professional" service“11”

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Default Value"negotiated”

Example:<XX.XX>

Added Disclosures
See section 3.2.2

The f ile allows the
population of one rate.
Capitation rates vary
based on age andgender bands. BCBSTX
will use a base rate.
N/A

11 corresponds with
where most capitation
services occur; there will
not be capitated rates
that vary by place ofservice18

code is required.
Allowed values:"professional,""institutional"

Billing Class

Billing Code Modifier

3.2.5.2

See table 3.5 f or thecomplete list
"professional"

Capitation agreements
are with medical groups
versus institutionalf acilities

N/A

Not reporting on or
populating rates basedon the billing code
modifier

An array of strings. Thereare certain billing code
types that allow for
modifiers (e.g., the CPT
coding type allows formodifiers). If a negotiatedrate f or a billing code typeis dependent on a modifier
f or the reported item orservice, then an additional
negotiated price object
should be included torepresent the difference.

Covered Services Object for Capitated Rates

All data elements below are populated for billing codes covered under the capitation agreement’s Divisionof Financial Responsibility (DOFR).

Data Element

CMS Definition

Default Value

Added Disclosures

Billing Code Type

Common billing code types.
Please see a list of
the currently allowed
codes at the bottom of thisdocument.

The billing code
type reporting
value for CPT,
HCPC, DRG, or
Revenue Codes.

See section 3.4

Billing Code Type
Version

There might be versions
associated withthe billing- codetype.

The billing code
type version.

N/A

The code used by a plan orissuer or its in-network
providers to identify healthcare items or services forpurposes of billing,
adjudicating, and paying
claims for a covered item orservice.

The
corresponding
billing code

In-network machinereadable f ile will only
include CPT, HCPC,
DRG, or Revenue Codebilling codes.

Brief description of theitem/service

The billing code
standard short orlong form
description

This will be the shortf orm description, if there
is no short form
description we will use
the long form description
in its place.

Billing CodeDescription

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3.3

Out-of-Network Allowed Amount File

While the In-Network MRF comprises of amounts payable for items and services based on contractual
payment arrangements with providers, the Out-of-Network (OON) Allowed Amount File is based on “theactual amount the Plan or Issuer paid to the out-of-network provider, plus the member share.” The Out-ofNetwork Allowed Amount File must also include both billed charges and out-of-network allowed amounts.
Billed charges are the total charges for an item or service billed to a Plan or Issuer by a provider.
The OON f ile will f ollow the following naming convention:<YYYY-MM-DD>_<payer or issuer name>_<Member-Facing Network>_<EIN>_<file type name>.<fileextension>
Note: the OON MRF will not be reflective of the EIN’s or Accounts historical rates only, it’s representativeof a sample of claims history per plan. The f inal OON MRF combines rates for plans in the same networkwith the same EIN into a single file.

3.3.1

Out-Of-Network Allowed Amount File Data Elements

At a high level, the Out-of-Network Allowed Amount File includes:

Data Element

CMS Definition

Default Value“Blue Cross and Blue Shield N/Aof <State>”

Entity Name

The legal name of theentity publishing the machinereadable f ile.

Entity TypeThe type of entity that is“health insurance issuer”
publishing the machine readable
f ile (a group health plan, healthinsurance issuer, or a third party
with which the plan or issuer has
contracted to provide therequired information, such as athird-party administrator, a healthcare claims clearinghouse, or ahealth insurance issuer that hascontracted with a group healthplan sponsor).

The date in which the f ile was
Last Updated
last updated. Date must be in an <YYYY-MM-DD>
On
ISO 8601 f ormat
VersionThe version of the schema forthe produced information

Billing code

Code used by a Plan, Issuer, or The corresponding billing
health care provider to identify code
health care items or services forpurposes of billing, adjudicating,and paying claims for a covered
item or service

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Added Disclaimers“1.3.1”In-network machinereadable f ile is available toboth ASO and non-ASO
plans, therefore, BCBSTX
is populating as “healthinsurance issuer”

Represents the day of the
f ile generation
This could change as new
CMS schema updates are
released
Out-of -network machinereadable f ile will only
include CPT, DRG, or
Revenue Code billing
codes.

20

Billing code
name

The billing code standard
short form description

This will be the short form
description, if there is no
short f orm description
BCBSTX will use the longf orm description in its
place.

The billing code standard
long form description

This will be the long form
description, if there is nolong f orm description,
BCBSTX will use the shortf orm description in its
place.

The billing code type
reporting value for CPT,
DRG, or Revenue Codes.

See section 3.4

This is name of the item/service
that is offered

Billing Code Brief description of the
Description item/service

Billing CodeType
Common billing code types

There might be versions
The billing code typeassociatedwiththebillingcode
version.
Billing Codetype. For example, Medicare's
Type Version
current (as of 5/24/21) MS-DRG
version is 37.2

N/A

The allowed amount must bereported as the actual dollar
amount the plan or issuer paid tothe out-of-network provider for a <X.XX>
particular covered item orservice, plus the participant’s,
benef iciary’s, or enrollee’s shareof the cost

Reported if it has 20 ormore claims in the defined
lookback period. This is
the BCBS paid amount.

The total dollar amount charges
f or an item or service billed to aBilled Charge<X.XX>
plan or issuer by an out-ofnetwork provider

Reported if it has 20 ormore claims in the defined
lookback period

AllowedAmountTIN Type

TIN Value

Place ofService CodeContains tax information on the “EIN”
place of business“NPI” is used if a provider
uses their Social Security
Number as their TIN

Either the unique Tax<Tax ID Number>
Identif ication Number issued by
Example: XXXXXXXXX
the Internal Revenue Service(IRS) f or type "EIN" or theprovider's NPI for TIN type "NPI"

NPI is used again if aprovider uses their social
security number as their
TIN.

CMS-maintained two-digit
The CMS place-of-service
codes available on CMS’ website Possible Values: 00, 01, 03, codes associated with thenegotiated rate site of
02, 08, 09, 10, 11, 12, 13,
14, 15, 17, 18, 19, 20, 21, service

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22, 23, 24, 25, 26, 31, 32,
33, 41, 42, 49, 50, 51, 52,
53, 54, 55, 56, 57, 58, 60, Place of Service Codes61, 62, 65, 71, 72, 81, 95, 99 will only be populated for“prof essional” providers

21

Allowed values: "professional""institutional"“prof essional” or“institutional”“Prof essional” is used
when reporting rates forprof essionals (individual
providers, medical groups,etc.) and “institutional”
when reporting rates forf acilities (hospitals, etc.)

Billing Class
Note: Providers who billon UB-04s will be
populated as “institutional”
and providers who bill on
CMS/HCFA 1500s will be
populated as“prof essional”
An array of strings. There are
N/Acertain billing code types thatallow f or modifiers (e.g., the CPT
coding type allows for modifiers).
Billing Code If a negotiated rate for a billingcode type is dependent on a
Modifier
modifier for the reported item orservice, then an additional
negotiated price object should be
included to represent thedif ference.
An array of individual (type 1 &2) provider identification
numbers (NPI)
NPI

3.3.2

Not reporting on or
populating rates based on
the billing code modifier

The providers National
If a provider does not
Provider Identifier (NPI)
have an NPI, BCBSTX
associated with the Tax
uses “0”Identification Number (TIN)
and negotiated rate

Patient Privacy Requirement for Out of Network

To ensure patient privacy, Payers or Issuers are required to only publish unique bill charge and allowed
amount combinations for providers with 20 or more occurrences per coverage agreement (plan), billingcode, TIN, NPI, and place of service.
Note: If the twenty (20) occurrence minimum is not met, the unique bill and charge allowed
amount combinations will not be included in the machine readable file. A reported allowed amount
may not ref lect the price history for all coverage options reported in the table of contents due aggregationof rates following the minimum claims calculations.
Since volume will vary in each lookback period associated with the month of file publication, it is possible
f or a unique bill charge and allowed amount combination to appear and disappear in the Out-of-Network
f ile f rom month-to-month.

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If f or a given plan there are no out-of-network values for a given month, the file header will be publishedwith the current date and no data included.

3.4

Billing Code Types

Negotiated rates for items and services can come from a variety of billing code standards. Below is a listof the billing code types BCBSTX reports in the in-network and out-of-network machine-readable files. For
a complete list of all allowable billing code type values visit the CMS GitHub site.

Standard Name

Reporting
Value

Additional Information

Current Procedural Terminology

CPT

American Medical Association

Healthcare Common Procedural Coding System

HCPCS

CMS HCPCS

Revenue CodeRC

What is a revenue code

Medicare Severity Diagnosis Related Groups

MS-DRGCMS DRGs

Ref ined Diagnosis Related Groups

R-DRG

Severity Diagnosis Related Groups

S-DRG

All Patient, Severity-Adjusted Diagnosis RelatedGroupsAPS-DRG

All Patient Diagnosis Related Groups

AP-DRGAll Patient Refined Diagnosis Related Groups

APR-DRG

Local Code Processing

Local

Custom Code

3.5

CSTM-00

AHRQ documentation

Represents all possible billingcode values for the definedbilling code type. Typically thiscan be used when anegotiated arrangement
applies to all codes under abilling code type.

Place of Service Codes

The f ollowing codes are the descriptions associated with the CMS PoS codes.

PoS

Description
1

Pharmacy2

Telehealth Provided Other than in Patient’s Home

3

School4Homeless Shelter

5

Indian Health Service Free-standing Facility

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6

Indian Health Service Provider-based facility

7

Tribal 638 Free-Standing Facility

8

Tribal 638 Provider-based Facility

9

Prison/Correctional Facility

10

Telehealth Provided in Patient’s Home11

Of f ice

12

Home

13

Assisted Living Facility

14Group Home *15

Mobile Unit

16

Temporary Lodging

17

Walk-in Retail Health Clinic

18

Place of Employment-worksite

19

Of f Campus-Outpatient Hospital

20

Urgent Care Facility

21

Inpatient Hospital

22

On Campus-Outpatient Hospital

23

Emergency Room – Hospital

24

Ambulatory Surgical Center

25

Birthing Center

31

Skilled Nursing Facility

32

Nursing Facility

33

Custodial Care Facility

34

Hospice41

Ambulance - Land

42

Ambulance – Air or Water

49

Independent Clinic

50

Federally Qualified Health Center

51

Inpatient Psychiatric Facility

52

Psychiatric Facility-Partial Hospitalization

53

Community Mental Health Center

54

Intermediate Care Facility/ Individuals with Intellectual Disabilities

55

Residential Substance Abuse Treatment Facility

56

Psychiatric Residential Treatment Center

57

Non-residential Substance Abuse Treatment Facility

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4

58

Non-residential Opioid Treatment Facility

59

Unassigned

60

Mass Immunization Center

61

Comprehensive Inpatient Rehabilitation Facility

62

Comprehensive Outpatient Rehabilitation Facility

65

End-Stage Renal Disease Treatment Facility

66

Unassigned

71

Public Health Clinic

72

Rural Health Clinic

81

Independent Laboratory

99

Other Place of Service

Data Retention

Only the most recent version of the rate files will be maintained in an online version. Accounts wishing toaccess historic records for internal analytics or inquiries are encouraged to download and store theavailable data each month.
MRF data is stored for seven years offline. Inquiries for historic data, required for an investigation or audit
may be obtained upon request and validation. For questions, refer to section 1.3 Contact Inf ormation.

5

Definitions
Term

Definition

Billed charge

Total charges for an item or service billed to a group health plan orhealth insurance issuer by a provider.

Billing code

Code used by a group health plan or health insurance issuer orprovider to identify health care items or services for purposes ofbilling, adjudicating, and paying claims for a covered item or service,including the Current Procedural Terminology (CPT) code,
Healthcare Common Procedure Coding System (HCPCS) code,
Diagnosis-Related Group (DRG) code, National Drug Code (NDC),
or another common payer identifier.

Centers for Medicare andMedicaid Services (CMS)

Federal agency within the United States Department of Health andHuman Services (HHS) that administers the Medicare program andworks in partnership with state governments to administer Medicaid,
the Children's Health Insurance Program (CHIP), and healthinsurance portability standards.

Covered items or services

Items or services, the costs for which are payable, in whole or inpart, under the terms of a group health plan or health insurance
coverage.

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Derived amountThe price that a group health plan or health insurance issuer assigns
to an item or service for the purpose of internal accounting,reconciliation with providers, or submitting data.

Diagnosis Related Group(DRG)

A patient classification scheme which provides a means of relating
the type of patients a hospital treats (i.e., its case mix) to the costs
incurred by the hospital.

Employer Identification
Number (EIN)The Employer Identification Number is a unique nine-digit number
assigned by the Internal Revenue Service to business entities
operating in the United States for the purposes of identification.

Health Insurance and
Health Insurance Oversight System (HIOS) number that uniquely
Oversight System (HIOS) ID identifies each new qualified health plan (QHP) approved by CMS.

In-network provider

Provider of any item or service with which a group health plan orhealth insurance issuer, or a third party for the plan or issuer, has acontract setting forth the terms and conditions on which a relevant
item or service is provided to a participant or beneficiary

Items or services

All encounters, procedures, medical tests, supplies, prescription
drugs, durable medical equipment, and fees (including facility fees),
provided or assessed in connection with the provision of health care

Machine readable file

Digital representation of data in a file that can be imported or read by
a computer system for f urther processing without humanintervention, while ensuring no semantic meaning is lost.

National Provider Identifier(NPI)

The National Provider Identifier (NPI) is a Health Insurance
Portability and Accountability Act (HIPAA) Administrative
Simplification Standard. The NPI is a unique identification number
f or covered health care providers. Covered health care providers
and all health plans and health care clearinghouses must use the
NPIs in the administrative and financial transactions adopted under
HIPAA. The NPI is a 10-position, intelligence-free numeric identifier(10-digit number). This means that the numbers do not carry otherinf ormation about healthcare providers, such as the state in which
they live or their medical specialty. The NPI must be used in lieu oflegacy provider identifiers in the HIPAA standards transactions.

Negotiated rate

Amount a group health plan or health insurance issuer has
contractually agreed to pay an in-network provider, including an innetwork pharmacy or other prescription drug dispenser, for covered
items and services, whether directly or indirectly, including through athird-party administrator or pharmacy benefit manager.

Out-of-network allowed
amountMaximum amount a group health plan or health insurance issuer will
pay f or a covered item or service furnished by an out-of-network
provider.

Out-of-network provider

Provider of any item or service that does not have a contract under aparticipant’s or beneficiary’s group health plan or health insurance
coverage to provide items or services.

Place of service codes

CMS-maintained two-digit codes that are placed on professional
claims, including Medicare, Medicaid, and private insurance, toindicate the setting in which a service was provided. Place of

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Service Codes. Centers for Medicare & Medicaid Services.
Available at: https://www.cms.gov/Medicare/Coding/place-of-servicecodes.
Tax Identification Number(TIN)

A Taxpayer Identification Number (TIN) is an identification number
used by the Internal Revenue Service (IRS) in the administration of
tax laws. It is issued either by the Social Security Administration(SSA) or by the IRS.

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Appendix
6.1 Checking your downloaded machine-readable file for integrity

The comparison of hash codes is an industry standard to confirm the integrity of a downloaded file. If
the hash code that is created from the source file is compared exactly to the hash code created fromthe downloaded file, this confirms that the file downloaded is the exact match to the file located in thesource, and that the file was not compromised nor corrupted during the download process.
The hash code for the source file that resides in the BCBS database will always be the same name of
the f ile plus the extension of ‘txt’ at the end of the file.

For example, for a compressed file, in the table of contents we may have:

Which will then have an associated .txt file available that will contain the 128-character hash codeof this file:

To view this .txt file, copy the .gz file from the table of contents and paste this into a browser. Add
the ‘.txt’ suffix to the end of the name in the browser and press enter. The .txt will then be
downloaded onto the user machine. Users may then go to their downloads to open this file andview the hash code.

To create the hash code of the downloaded file for comparison to the BCBS hash code, the following
may be performed, per operating system. We are leveraging SHA-512 method of hashing.
Insert downloaded file name for 'pathToFile':
Perf orm “Command Prompt” in Windows:
certUtil -hashfile pathToFile sha512
Perf orm “Command Prompt” with Mac:shasum -a 512 pathToFile
Perf orm “Command Prompt” in Unix (CentOS):
sha512sum pathToFile
The hash value resulting from the above commands may then be compared to the hash value within
the .txt extension of the file to confirm an exact match. This method may be used to verify both thecompressed and uncompressed machine-readable files.

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