These attributes are not required for files that will be reporting multiple plans per file but ARE REQUIRED for single plans that are being reported that do not wish to create a table-of-content file. For payers/issuers that will be reporting multiple plans per file, these attributes will be required in a table-of-contents file.

The out-of-network object contains information related to the service that was provided out-of-network.

The allowed amounts object documents the entity or business and service code in where the service was provided out-of-network.

For most businesses reporting cases, a tax identification number (tin) is used to represent a business. There are situations where a provider's social security number is still used as a tin. In order to keep private personally identifiable information out of these files, substitute the provider's npi number for the social security number. When a npi number is used, it is assumed that the provider would otherwise be reporting by their social security number.

The payment object documents the allowed amounts the plan has paid for the service that was provided out-of-network.

The allowed_amount is each unique allowed amount, reflected as a dollar amount, that a plan or issuer paid for a covered item or service furnished by an out-of-network provider during the 90-day time period that begins 180 days prior to the publication date of the machine-readable file. To protect patient privacy, a plan or issuer must not provide out-of-network allowed amount data for a particular provider and a particular item or service when compliance would require the plan or issuer to report out-of-network allowed amounts paid to a particular provider in connection with fewer than 20 different claims for payment. Issuers, service providers, or other parties with which the plan or issuer has contracted may aggregate out-of-network allowed amounts for more than one plan or insurance policy or contract. If information is aggregated, the 20 minimum claims threshold applies at the plan or issuer level.

The provider object defines the list of NPIs and their billed charges for the service provided out-of-network.

Negotiated rates for items and services can come from a variety of billing code standards. The list of possible allowed values is in the following table with the name of the standard and the values representing that standard that would be expected if being reported on. For standards that are used for negotiated rate that are not in the following table, please open a discussion to potentially add a new standard to the table.