The Transparency in Coverage Final Rule requires us to display machine-readable files
Health insurers are required to publicly display certain health care price information via machine-readable files on their websites beginning in 2022. These machine-readable files will include negotiated rates with in-network providers.
CMS requires that machine-readable files (MRF) be posted in the JSON format. See CMS specifications.
The intended users of MRFs are researchers, regulators, and application developers; MRFs are not intended for member use. In 2023 members should have access to a user-friendly cost calculator tool with pricing information for 500 "shoppable services", as defined by CMS.
WellFirst Health price transparency information may not be complete at this time. We are actively working to supplement file content.
If you have questions, see the following sites for detailed information:
Amounts presented in the Machine Readable files are general, not member-specific or user-specific, per CMS Requirements. They don't include provider taxes, claim edits, deductibles, co-pays and out of pocket maximums which would be applied to a specific member.
Some services described in the Machine Readable files may not be available to everyone due to medical necessity or other restrictions. They are subject to "prerequisites to coverage," that is, conditions such as prior authorization may be needed before the service can be provided.
WellFirst Health is using the CMS File Schema, which provides for reporting of negotiated rates at the product level, not the benefit plan level. Some services shown might not apply to all benefit plans within a product. If you need self-insured benefit plan information, please confirm with your WellFirst Health account representative the product under which your self-insured plan is included.
We work with partners including Leased Networks for some services. WellFirst Health does not have visibility to the contracts which our partners have with their providers and is depending partner information being complete and accurate based on our partners' good faith efforts. We don't have control over whether a given partner's provider is available at any given time.
Information is included for only the services that a provider or facility is licensed to furnish within their scope of service.
Any rates presented in the Machine Readable file for Diagnosis Related Groups (DRGs), also known as our Severity Diagnosis Related Groups (MS-DRGs), All Patient Diagnosis Related Groups (APDRGs) and All Patient Refined Diagnosis Related Groups (APR-DRGs) are based on the current CMS standards. DRGs will vary case by case and patient by patient. In some situations, there are "outliers" to DRGs which may be significantly higher cost than what is shown in the files.
WellFirst Health doesn't imply alignment with pricing information furnished by any other payer and does not guarantee that its information to be a basis for comparison with other payers' Machine Readable file data.
WellFirst Health contracts using a "Percent of Billed Charges" submitted by providers. We are dependent on submitted claims to be able to determine these In Network Rates. Where providers have never submitted claims against a specific service for which the In Network Rate is a percent of billed charges, we have made a good faith effort to estimate the In Network Rate based on available information including but not limited to comparable rates from CMS and other sources.
If a provider bills a lower rate than what is allowed in the contract, including as a percent of charges, we include that lower rate in the In Network File in order to reflect the current state of the provider billing amounts.
Some WellFirst Health products include in network benefits in states outside our usual service area. As applicable, we have included these rates for these services as part of our in network files.
For Allowed Amount (Out of Network) Files: COVID testing under state programs is currently covered by the state. There is no allowed amount paid by or billed to WellFirst Health. Therefore these items are not included.