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.

This type defines an in-network object.

This type defines a negotiated rate object.

Either a provider_groups or provider_references attribute will be required in the Negotiated Rate Object to map the provider network to the item/service that is being documented. The schema requirements can be found here.

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.

In contractual arrangements that are only made at the TIN level, where NPIs are unknown or otherwise unavailable, the value "0" should be reported for the NPI field. In contractual arrangements where both the NPI and TIN are available, both are required to be disclosed.

This type defines a provider reference object. This object is used in the provider_references array found on the root object of the in-network schema. The Provider Group Id is a unique interger ID that is defined by the user to be referenced in the Negotiated Rate Details Object in the provider_references array. An example of using provider references can be found in the definition of provider reference objects and then the usages of the provider_group_ids in the negotiated rate object.

Either a provider_group or location attribute will be required in the Provider Reference Object.

The negotiated price object contains negotiated pricing information that the type of negotiation for the covered item or service.

For negotiated_type there are five allowable values: "negotiated", "derived", "fee schedule", "percentage", and "per diem". The value are defined as:

• negotiated: If applicable, the negotiated rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider, except for prescription drugs that are subject to a fee-for-service reimbursement arrangement, which must be reported in the prescription drug machine-readable file. If the negotiated rate is subject to change based upon participant, beneficiary, or enrollee-specific characteristics, these dollar amounts should be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant, beneficiary, or enrollee-specific characteristics.
• derived: If applicable, the price that a plan or issuer assigns to an item or service for the purpose of internal accounting, reconciliation with providers or submitting data in accordance with the requirements of 45 CFR 153.710(c).
• fee schedule: If applicable, the rate for a covered item or service from a particular in-network provider, or providers that a group health plan or health insurance issuer uses to determine a participant’s, beneficiary’s, or enrollee’s cost-sharing liability for the item or service, when that rate is different from the negotiated rate.
• percentage: If applicable, the negotiated percentage value for a covered item or service from a particular in-network provider for a percentage of billed charges arrangement. Note: percentage values entered into the negotiated_rate attribute are to be a whole number percentage of the negotiated arrangement (i.e. 40.5% should be entered as 40.5 and not .405).
• per diem: If applicable, the per diem daily rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider.

For expiration_date, there may be a situation when a contract arrangement is "evergreen". For evergreen contracts that automatically renew on a date provided in the contract, the expiration date you include should be the day immediately before the day of the automatic renewal.

In situation where there is not expiration date (see discussion here), the value 9999-12-31 would be entered.

For service_code, if a negotiated rate for either "professional", "institutional", or "both" billing_class is the same for all service_codes, the custom value of CSTM-00 can be used to avoid listing all possible service codes.

{
 "negotiation_arrangement": "ffs",
 "name": "Knee Replacement",
 "billing_code_type": "CPT",
 "billing_code_type_version": "2020",
 "billing_code": "27447",
 "description": "Arthroplasty, knee condyle and plateau, medial and lateral compartments",
 "negotiated_rates": [{
   "provider_groups": [{
     "npi": [6666666666],
     "tin":{
       "type": "npi",
       "value": "6666666666"
     }
   }],
   "negotiated_prices": [{
     "negotiated_type": "negotiated",
     "negotiated_rate": 123.45,
     "expiration_date": "2022-01-01",
     "service_code": ["CSTM-00"],
     "billing_class": "professional"
   }],
 }]
}

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.

There are custom billing_code_types defined for the Transparency in Coverage rule. These coding types are prefixed with CTSM-. These coding types are meant to help with generic reporting. The complete list can be found the in following table.

The following are custom defined billing codes that can be applied to any billing_code_types:

The following would applied the negotiated_price object(s) to all CPT codes:

{
 "negotiation_arrangement": "ffs",
 "name": "CPT codes",
 "billing_code_type": "CPT",
 "billing_code_type_version": "2020",
 "billing_code": "CSTM-00",
 "description": "All CPT codes",
 "negotiated_rates": [{
   "provider_groups": [{
     "npi": [6666666666],
     "tin":{
       "type": "npi",
       "value": "6666666666"
     }
   }],
   "negotiated_prices": [{
     "negotiated_type": "negotiated",
     "negotiated_rate": 12.45,
     "expiration_date": "2022-01-01",
     "service_code": ["18", "19", "11"],
     "billing_class": "institutional"
   }]
 }

The following would applied the negotiated_price object(s) to each billing_code_type defined at here. NOTE: the billing_code_type_version would apply to the current plan's year.

{
 "negotiation_arrangement": "ffs",
 "name": "All coding types",
 "billing_code_type": "CSTM-ALL",
 "billing_code_type_version": "2022",
 "billing_code": "CSTM-00",
 "description": "All codes possible",
 "negotiated_rates": [{
   "provider_groups": [{
     "npi": [6666666666],
     "tin":{
       "type": "npi",
       "value": "6666666666"
     }
   }],
   "negotiated_prices": [{
     "negotiated_type": "negotiated",
     "negotiated_rate": 12.45,
     "expiration_date": "2022-01-01",
     "service_code": ["18", "19", "11"],
     "billing_class": "institutional"
   }]
 }