Consolidated Appropriations Act (CAA) Transparency in Coverage (TiC)
Machine Readable Files (MRFs)
PAI is hosting access to the CAA TiC required Machine Readable Files (MRFs), for our employer group customers, reflecting:
- In-Network rates; and
- Out-of-Network allowed amounts.
PAI is following the guidelines available on the GitHub website for posting MRFs.
- What is a machine-readable file (MRF)?
A machine-readable file is defined as a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention, while ensuring no semantic meaning is lost. The Transparency in Coverage Rule (TiC) specifies that insurers/plans must create and publicly post machine-readable files (MRF) with detailed in-network and out-of-network pricing data. TiC requires each machine-readable file to use a non-proprietary, open format.
- What data is available in the MRFs provided?
The MRFs we produce only contain the data we administer and maintain. This includes MRFs with preferred provider organization (PPO) in-network pricing and out-of-network pricing. These files include pricing for drugs* covered under the medical plan.
Out-of-network MRFs are created for each group.
If a plan uses a third-party vendor (such as carved-out behavioral health), then the group should work with that vendor to determine whether it is providing a similar solution.
*The prescription drug file compliance date has been postponed, but we will be compliant with regulations when that date is announced.
- How will users select the correct files?
Our web portal is set up to allow users to search for MRFs by the employer’s IRS Employer Identification Number (EIN). The search returns all the relevant files for the employer based on their EIN ID and network code.
For groups with custom pricing, such as a hospital employer with a domestic pricing tier, we generate the in-network MRFs that apply to that tier. These files are available at our public website for that employer only.
- How many files are created for a group?
An in-network file is created for each network a group uses and includes a separate file for each plan. The out-of-network file is a single file.
- How often are the MRFs be updated?
The files are updated monthly.
- Does PAI create these files and/or the website internally or utilize a subcontractor?
We create these files internally.
- In what format do you provide the files?
Files are in JSON format.
- Can plan sponsors link to the files?
These files are accessible through this publicly available website/webpage. Plan sponsors may link to those files as desired.
- Does PAI provide employers with MRFs on a monthly basis?
Because of sharing limitations due to file size, the machine-readable files are only be made available on the public website.
- Are there any fees to employers to get the MRFs?
- Are members able to access the MRFs?
Anyone can visit our public website and download files based on employer group EIN. However, these files are not intended for member consumption. Members who wish to review pricing for specific provider or procedures should contact our PAI Customer Service Team.
- How do you monitor and validate your processes to ensure the ongoing accuracy of the data in the files?
Quality assurance processes is an integral part of our solution design for the monthly file postings.