Transparency in Coverage Machine-Readable Files
The following information is for data aggregators who can download and interpret machine-readable files. The machine-readable files referenced on this page contain our pricing information as part of the Transparency in Coverage rules.
Information for Members
Please note that the information on this page is for data aggregators. The federal requirements specifically call for machine-readable files, so you will not likely be able to download and interpret the data on your own. To get cost estimates for common treatments and procedures, use our Estimate Medical Costs tool. Estimates are based on what your plan covers.
Transparency in Coverage Overview
The Transparency in Coverage Final Rules require us to disclose on a public website the following information in two separate categories of machine-readable files:
- In-network provider rates for covered items and services
- Out-of-network allowed amounts and billed charges for covered items and services
Pricing information for covered prescription drugs are on hold pending further guidance from the Centers for Medicare and Medicaid Services (CMS).
How to Use Machine-Readable Files
A machine-readable file is a digital representation of information in a file that can be read and processed by a computer system. Examples of machine-readable formats include XML, JSON and CSV. For the Transparency in Coverage mandate, we are using the JSON file format.
A JSON file is a plain text file that can be opened, modified, and saved without a special software application. However, doing so may break special formatting in the file which may cause the application to fail. The following applications will open a JSON file without changing any formatting:
- Microsoft Notepad (Windows)
- Apple TextEdit (Mac)
- Vim (Linux)
- GitHub Atom (cross-platform)
A JSON file can also be opened in the Google Chrome and Mozilla Firefox web browsers by dragging and dropping the file into the browser window.
Note: Due to their size and readability, JSON files are intended for use by data aggregators using special computer programs for gathering and expressing raw data in summary form for statistical analysis.
Contents of Machine-Readable Files
In the machine-readable files, we’re mandated to share every price for each covered item or service by provider and commercial product. Different files are generated for each employer group and include reimbursement rates for all provider types, including physician, hospital, and ancillary services.
The Transparency in Coverage rules require two separate machine-readable files for in-network rates and out-of-network allowed amounts. Given the large size of the files, the data has been broken into hundreds of files for each of the two categories (in-network and out-of-network). Our files consist of the following:
- In-Network Rate File: Approximately 400 files, 2.5 TB in total
- Out-of-Network Allowed Amount File: Approximately 220 files, 100 GB in total
Guidance for Data Aggregators
- Size of Full Set: Approximately 2.5 TB
- Average Size: 7 GB per individual file
- Format: JSON
- Search Criteria: HIOS (Health Insurance Oversight System), EIN (Employer Identification Number) or File Name
- Other: ICD-10-PCS codes are represented in our cost tool under the primary/parent APR-DRG code.
Review all machine-readable file content under General Info before submitting a question. Still have a question? Submit your question using the form below.
Submit a Machine-Readable File Question