Transparency in coverage machine-readable files

Machine-readable files table of contents URL:

https://mktg.bluecrossmn.com/mrf/2024/2024-09-01_Blue_Cross_and_Blue_Shield_of_Minnesota_index.json

Instructions for developers

Blue Cross Blue Shield of Minnesota uses the Table of Contents approach for Machine-Readable Files. In the table of contents, plans are mapped to a collection of in network files that reflect providers and rates for the selected plan network. Plan files are presented based on size, geography, or other defining criteria. For this reason, it is possible that a billing code may be repeated in multiple files. However, the providers and the rates will be different and are not duplicated across the files.

The table of contents file will be made available upon completion of a quality check prior to submission. We anticipate files to be made available as close to the beginning of the month as is feasible. 

The file name of the table of contents will always follow this pattern – YYYY-MM-01_BlueCrossBlueShieldMinnesota_index.json. For example: The file for October 2022 will be ‘2022-10-01_BlueCrossBlueShieldMinnesota_index.json’.  

Note: Although there is a day portion to the month – this value will not change and will always be a 01.

The base path for this file is https://mktg.bluecrossmn.com/mrf/YYYY/ - this will remain constant. 
For example: The October 2022 file is at URL https://mktg.bluecrossmn.com/mrf/2022/2022-10-01_BlueCrossBlueShieldMinnesota_index.json

Recommended actions:

1. Create a job that pings this URL each day after the first of the month, looking for the month value to change from your last processed month.  
2. Download and parse the table of contents as per the schema defined by CMS here: https://github.com/CMSgov/price-transparency-guide/tree/master/schemas/table-of-contents

Note: Blue Cross Blue Shield of Minnesota supports numerous plans, and our networks are nationwide as part of the Blue Cross Blue Shield network. The table of contents itself is a file size greater than 10MB – however, some of the referenced files can be in the hundreds of GB in size and they are compressed.  

Not all files use the same compression, and you will need to detect the compression mechanism based on the suffix of the file (.gz or .zip). 

After decompression, file format will follow the CMS schema for in network files as defined here: https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/in-network-rates/in-network-rates.json
And for the allowed amount files as defined by the schema here: https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/allowed-amounts/allowed-amounts.json.

Overview

Insurers and plans will be required to make available to the public, pricing files to be updated monthly, effective for plan years on and after January 1, 2022.

• Enforcement date for in and out of network machine readable files is July 1, 2022
• Enforcement date for the pharmacy machine-readable file is delayed pending further rule-making

Federal rules

Excerpt from the original Full Final Rule

Dated November 12, 2020

View Full Final Rule

“3. Requirements for Public Disclosure of In-network Provider Rates for Covered Items and Services, Out-of-network Allowed Amounts and Prescription Drug Pricing Information Through Machine-readable Files under 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212.”

Excerpt from Final Rule Fact Sheet

Dated October 29, 2020

View Final Rule Fact Sheet

“Group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to make available to the public, including stakeholders such as consumers, researchers, employers, and third-party developers, three separate machine-readable files that include detailed pricing information.

• The first file will show negotiated rates for all covered items and services between the plan or issuer and in-network providers. (Note: enforcement delayed until 7/1/22 per FAQS ABOUT AFFORDABLE CARE ACT AND CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION PART 49 (PDF))

• The second file will show both the historical payments to, and billed charges from, out-of-network providers. Historical payments must have a minimum of twenty entries in order to protect consumer privacy. (Note: enforcement delayed until 7/1/22 per FAQS ABOUT AFFORDABLE CARE ACT AND CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION PART 49 (PDF))

• The third file will detail the in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level. (Note: delayed pending further rulemaking, per FAQS ABOUT AFFORDABLE CARE ACT AND CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION PART 49 (PDF))

Plans and issuers will display these data files in a standardized format and will provide monthly updates. This data will provide opportunities for detailed research studies, data analysis, and offer third party developers and innovators the ability to create private sector solutions to help drive additional price comparison and consumerism in the health care market. These files are required to be made public for plan years that begin on or after January 1, 2022.”