Transparency in coverage data

Helping you understand your healthcare costs.

You may have heard about the federal Transparency in Coverage Rule, which is intended to help commercial members understand healthcare costs. Mass General Brigham Health Plan is committed to this rule and shares its goal of empowering our members.

Machine-readable files

In alignment with the Transparency in Coverage rule, Mass General Brigham Health Plan publicly displays information, called machine-readable files. These files are updated on a monthly basis and include in-network negotiated provider rates and out-of-network provider allowed amounts.

For additional information about the Transparency in Coverage Rule, please visit the Centers for Medicare and Medicaid Services website. You can also review our Frequently Asked Questions (FAQs) below.

In addition, Mass General Brigham Health Plan commercial members have access to a variety of resources for understanding health care costs. This includes our cost estimator tool for tracking cost sharing and viewing payments within your plan, which can be accessed through the Mass General Brigham Health Plan Member app and Member portal. Please note: machine-readable files can include provider reimbursement rates for services that may have restrictions within your specific plan.

Click here to access machine-readable files for Mass General Brigham Health Plan plans. Please note: to use the machine-readable files, the member should use an appropriate online JSON tool to format the data.

*Multiplan (PHCS) wrap provider in-network only applies to the state of New Hampshire, therefore, please refrain from using this file in its entirety and use these rates for providers in the state of New Hampshire only.

**Multiplan/Data iSight out-of-network provider network only applies to the states of Massachusetts and New Hampshire, therefore, please refrain from using this file in its entirety and use these rates for providers in Massachusetts and New Hampshire states only.

Download a PDF version of this FAQ.

What are machine-readable files?
As part of the federal Transparency in Coverage Rule, health insurers and self-funded group health plans or employer-sponsored plans are required to publicly display information, called machine-readable files. These files are updated monthly and include in-network negotiated provider rates and out-of-network provider allowed amounts.

What is included in machine-readable files?
These files include a Table of Contents, as well as in-network negotiated provider rates and out-of-network provider allowed amounts that each contain vendor file references.

What is included in the Table of Contents?
The Table of Contents (TOC) includes an index of the in-network negotiated provider rates and out-of-network provider amounts based on a given plan and product line.

What is an in-network rate?
An in-network rate is the amount that a health insurer has agreed to pay a contracted provider for healthcare services. As part of the Transparency in Coverage Rule, these rate files include negotiated rates, underlying fee schedule rates used to determine cost sharing, or derived amounts, according to the rate that is applicable to the health insurer’s reimbursement model.

What is an out-of-network allowed amount?
An out-of-network allowed amount is the maximum payment that a health insurer will pay for a healthcare service from a non-participating provider. As part of the Transparency in Coverage Rule, these rate files include the allowed amount for those items and services, including each unique amount associated with the individual provider.

When will machine-readable files be available?
In compliance with federal guidance related to the Transparency in Coverage Rule, machine-readable files became publicly available on July 1, 2022, and will be generated on a monthly basis moving forward.

How can I access machine-readable files?
In compliance with regulatory guidelines, machine-readable files are available through a public link on the Mass General Brigham Health Plan website. The files can be accessed using a JavaScript Object Notation (JSON) viewer. For additional information on formatting and accessing machine-readable files, please visit the GitHub on the Centers for Medicare & Medicaid Services (CMS) website.

To help members understand their healthcare costs, Mass General Brigham Health Plan members also have access to a variety of resources, such as our cost estimator tool to track the status of claims and cost sharing within your plan through the Mass General Brigham Health Plan Member app and Member portal. Please note, machine-readable files can include provider reimbursement rates for services that may have restrictions within your specific plan.

How can I identify different providers in machine-readable files?
Through these machine-readable files, users can find information for a variety of our plans, including Health Maintenance (HMO), Preferred Provider Organization (PPO), and high-performance network products. To locate specific providers, users can reference providers based on their National Provider Identifiers (NPI) code, which can be found on the CMS website: https://npiregistry.cms.hhs.gov/.

What should I do if I notice an issue or need assistance?
We are committed to the federal Transparency in Coverage rule and providing high-quality information. If you experience any technical issues or need additional support, please contact us at 866-414-5533 or HealthPlanCustomerService-Members@mgb.org, and a representative will be able to assist you.

What are the system and browser requirements for accessing machine-readable files?
Machine-readable files can be accessed using any internet-based browser with download capabilities. These files are highly complex, comprehensive, and can exceed 1 gigabyte in file size, which may require a computer software with higher Random Access Memory (RAM) or storage.

How often are machine-readable files updated?
In compliance with regulatory guidelines, machine-readable files are updated on a monthly basis.

Prescription drug spending report

As part of the No Surprises Act, which is primarily intended to establish surprise billing protections for commercial members, group health plans and health insurance issuers—including Mass General Brigham Health Plan—are required to submit prescription drug spending reports starting in late 2022. These reports are expected to show how prescription drugs contribute to the overall cost of healthcare coverage.

For additional information about prescription drug spending, please visit the CMS website. You can also review our FAQs below.

Download a PDF version of this FAQ.

What are prescription drug spending reports?
As part of the No Surprises Act, group health plans and health insurance issuers are required to submit information about prescription drug spending starting in late 2022. These reports outline prescription drug expenses for medical and retail pharmacy claims for the previous two calendar years.

What is included in prescription drug spending reports?
These reports are required to include information on the most frequently dispensed and costly drugs, as well as prescription drug rebates.

How is Mass General Brigham Health Plan supporting prescription drug spending reports?
Mass General Brigham Health Plan is committed to working with commercial accounts and consultants to submit prescription drug spending reports. Please see below for the list of information that we are able to provide as part of the CMS report template and codes.

For accounts that include prescription drug coverage administered through Mass General Brigham Health Plan, we will work in collaboration with CVS Caremark to compile and submit the following data reports and narrative responses:

P1 – Individual and Student Market Plan List
P2 – Group Health Plan List
D1 – Premium and Life Years
D2 – Drugs Covered under Hospital or Medical Benefits
D3 – Top 50 Most Frequent Brand Drugs
D4 – Top 50 Most Costly Drugs
D5 – Top 50 Drugs by Spending Increase
D6 – Pharmacy Totals
D7 – Pharmacy Rebates by Therapeutic Class
D8 – Pharmacy Rebates for the Top 25 Drugs
Employer Size for Self-Funded Plans
Wellness Services
Drugs Missing from the CMS Crosswalk
Drugs Covered under Hospital or Medical Benefits
Prescription Drug Rebate Descriptions
Allocation Methods for Prescription Drug Rebates
Impact of Prescription Drug Rebates

For accounts that do not include prescription drug coverage administered through Mass General Brigham Health Plan, we can submit the following data reports and narrative responses:

P2 – Group Health Plan List*
D1 – Premium and Life Years
D2 – Drugs Covered under Hospital or Medical Benefits
Employer Size for Self-Funded Plans
Wellness Services
Please note, we cannot support the following data as we do not have full access to retail pharmacy data for self-insured accounts with the Pharmacy Benefits Manager carved out:
- D3 – Top 50 Most Frequent Brand Drugs
- D4 – Top 50 Most Costly Drugs
- D5 – Top 50 Drugs by Spending Increase
- D6 – Pharmacy Totals
- D7 – Pharmacy Rebates by Therapeutic Class
- D8 – Pharmacy Rebates for the Top 25 Drugs
- Drugs Missing from the CMS Crosswalk
- Prescription Drug Rebate Descriptions
- Allocation Methods for Prescription Drug Rebates
- Impact of Prescription Drug Rebates

*Please note, the P2 report attestations are limited to benefits administered by Mass General Brigham Health Plan.

For general inquiries about Mass General Brigham Health Plan’s prescription drug spending reports, who should I contact?
You can contact our Broker & Account Services team via email or call us at 866-643-8392.

How often are the prescription drug spending reports required to be submitted?
In compliance with regulatory guidelines, the prescription drug spending reports are required to be submitted on a periodic basis.

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Transparency in coverage data

Helping you understand your healthcare costs.

Machine-readable files

Prescription drug spending report

Transparency in coverage data

Helping you understand your healthcare costs.

Machine-readable files

Additional resources

Machine-readable files

Frequently asked questions

Prescription drug spending report

Prescription drug spending FAQs