This page contains information in compliance with the U.S. Department of Health & Human Services (HHS), Department of Labor, and Department of the Treasury-issued Transparency in Coverage Rule issued in November 2020.
The links on this page are to machine-readable files (MRFs) that list in-network rates and out-of-network allowed amounts for providers. The files will be made public for plan years that begin on or after January 1, 2022 and will be refreshed monthly.
In Network Rate
- The actual amounts paid to a contracted provider may differ from the rates listed on the MRFs due to member-specific characteristics and the use of modifiers, bundling, and the application of other contract terms and policies for a service provided to a specific member.
- The providers included, and rates listed within the MRFs, are subject to change retroactively based on ongoing negotiations with providers.
- For agreements with providers that use alternative reimbursement arrangements for items and services are not specified, CHPW will rely on the enforcement safe harbor as set forth in FAQs About Affordable Care Act Implementation Part 53 (issued April 19, 2022).
- Payment based on Medicare allowable rates. Actual allowable amounts may differ from those listed in the MRFs based on actual claims and member-specific characteristics.
- Certain provider agreements have, in addition to the specific contract rates listed for services and/or items within the MRFs, a default process for calculating payment for other services and/or items that may be covered and provided (e.g., a percent of billed charges). Such pricing provisions are not reflected within the MRFs.
- Inpatient bill code rates. The per diem negotiated rate within MRFs may change depending on the duration of an inpatient stay, with the MRFs at this time reporting the negotiated per diem rate applicable initially.
Allowed Amount
- The allowed amount files represented here include 20 or more occurrences of the same billing code from a provider group (based on its EIN and not the respective benefit plan). Changes to the selection criteria for this file (MRF2) to reflect billing codes of the benefit plan will be updated as soon as possible.
Machine Readable Files
The following machine readable files are updated monthly:
What Are Machine Readable Files?
MRFs are a kind of protected digital file format that this provider data or information from various sources is transmitted to CHPW. CHPW’s computer systems can read the information and then present it for public’s use on this page. The MRF format ensures that there can be no alterations or changes to that data as it is transferred.
