Transparency in Coverage Rule: Machine Readable Files
In 2020, the “Departments” (HHS, DOL, Treasury) within the Federal Government finalized the Transparency in Coverage rule. This legislation was instituted with the intention of improving the affordability and transparency of healthcare.
A key provision within this rule requires health insurers and plans to publish two separate machine-readable files by July 1, 2022.
- In-Network Negotiated Rates: All rates for covered items and services that have been negotiated between a plan/issuer and their in-network providers.
- Out-of-Network allowed Rates: A historical allowed amount in claims paid (more than 20) and the billed charges from out-of-network providers over the previous 90 days
At StayWell, we are committed complying with all legal responsibilities related to all laws, rules and regulations.
In-Network
Out-Of-Network
Disclaimer
Transparency in Coverage final rules require health plans and health insurance issuers to disclose in-network negotiated rates and out-of-network billed charges/historical allowed amounts through two machine-readable files posted on an internet website.
The machine-readable files above are published to comply with federal regulations.
Not all services and procedures listed are offered by providers. Available services may change from time to time.
The base rates reflected are unadjusted for the participants, beneficiaries, or for enrollee-specific factors. Provider rates are subject to change throughout the year which will be reflected in the next file update.
Though these files may provide information on the cost of a specific service item, the actual payment for a related patient claim may be different and may be affected by a variety of factors including, but not limited to, the mix of items, the use of modifiers, eligibility/benefit determinations and other negotiated payment methodologies.
If there is a discrepancy between a negotiated rate listed in the machine-readable file(s) and the contracted rate applicable to a specific patient claim, the terms of the provider contract will prevail.
Transparency in Coverage Rule: Price Comparison Tool
In the year 2020, the Department of Health & Human Services together with the Department of Treasury and the Department of Labor established the Transparency in Coverage rule — a significant legislative initiative aimed at enhancing accessibility and transparency of healthcare services for consumers.
Under this rule, health insurers are required to provide an online price comparison tool integrated with a comprehensive provider directory. With this, the StayWell team is pleased to introduce to our members the StayWell Price Comparison Tool by Sapphire Digital.
StayWell Price Comparison Tool
In our continued efforts to give StayWell members effective tools to help them along their health journey, the StayWell Price Comparison Tool is designed to provide you with personalized estimates of out-of-pocket expenses and facilitate price comparisons for specific services so you can make the right decisions in your healthcare. With the StayWell Price Comparison Tool you will be able to:
- Browse through healthcare services based on billing codes or description
- Review your accumulated deductible or other out-of-pocket expenses to-date.
- Obtain detailed cost estimates.
- Examine influencing factors affecting costs, such as service location or participating providers.
- Search for providers based on geographical location, provider specialty, and range of services offered.
Please note that while our site is still undergoing occasional updates, it is currently fully functional. For assistance or support with the price comparison tool, or if you have any questions, comments or concerns regarding your covered benefits please reach out to our dedicated StayWell Customer Service team by phone at (671) 477-5091 or by email at [email protected]. Our team is here to assist you and provide all the necessary information to help you make informed decisions about your healthcare costs.
Disclaimers and Disclosures
The online price comparison tool provides StayWell members the ability to search for costs associated with specific billing codes contracted between your healthcare provider and StayWell. Please note that not all listed services and procedures are guaranteed to be offered by providers. Service availability may vary. For members with dual coverage please note that claims and out-of-pocket maximums will reflect only from the primary record.
If a requested health service or billing code is not displayed, please contact StayWell Customer Service at (671) 477-5091 or email [email protected] for further assistance.
The information provided by this tool is not a guarantee of coverage, payment or authorization for a particular item or service. The estimates provided by this tool are not an exact calculation of your actual cost and do not reflect all the items conditions, limitations and exclusions that may apply to your coverage. Actual cost may differ from the estimate depending on the actual items and services received at the point of care.
This tool is intended to be a reference tool and is not a substitute for the medical decision making of your healthcare provider. Be sure to consult with your own physician about your particular medical condition, treatment and facility options. The information within this tool is not a recommendation or endorsement of any particular healthcare facility or its services and does not guarantee services will be available or will be of any particular cost.
Estimates do not take into account Medicare claims, claims paid after a primary health plan has paid (secondary coverage), costs for services provided in addition to the primary healthcare service selected, emergency cases and claims that include numerous complications