Consolidated Appropriations Act (CAA) Transparency in Coverage (TiC) + Machine Readable Files (MRFs)

Compliance Alert
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: 

  1. In-Network rates; and 
  2. 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 will be available in the MRFs provided? 

The MRFs we produce only contain the data we administer and maintain. This will include MRFs with preferred provider organization (PPO) in-network pricing and out-of-network pricing. These files will include pricing for drugs* covered under the medical plan. 

Out-of-network MRFs will be 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 will be set up to allow users to search for MRFs by the employer’s IRS Employer Identification Number (EIN) or Health Insurance Oversight System (HIOS) ID, if applicable. The search will return all the relevant files for the employer based on their EIN/HIOS ID and network code. 

For groups with custom pricing, such as a hospital employer with a domestic pricing tier, we will generate the in-network MRFs that apply to that tier. These files will be available at our public website for that employer only.

How many files will be created for a group? 

An in-network file will be created for each network a group uses and will include a separate file for each plan. The out-of-network file will be a single file. 

How often will the MRFs be updated? 

The files will be updated monthly.

Will you create these files and/or the website internally or utilize a subcontractor? 

We will create these files internally. 

In what format will 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. 

Will PAI provide employers with MRFs on a monthly basis? 

Because of sharing limitations due to file size, the machine-readable files will only be made available on the public website.

When will your platform be ready to launch? 

Files are available for download without login.

Are there any fees to employers to get the MRFs?

No

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 will you monitor and validate your processes to ensure the ongoing accuracy of the data in the files? 

Quality assurance processes will be an integral part of our solution design for the monthly file postings.