Transparency in Coverage Rule

The Transparency in Coverage rule was finalized in 2020 and requires insurers and group health plans, including self-funded clients, to provide access to information about the cost of a covered item or service before receiving care.

There are three phases to the requirements of the Transparency in Coverage rule. Each phase is outlined below.

 

Phase 1: July 1, 2022

Machine-Readable File Access

Sanford Health Plan will begin posting machine-readable files in JSON file format. These files will contain pricing information for covered items and services.

The machine-readable files contain the following sets of costs for items and services:

  • In-network machine-readable file: Rates for all covered items and services between the plan or issuer and in-network providers.
  • Out-of-network machine-readable file: Allowed amounts for and billed charges from out-of-network providers.

Files will be updated on the first of each month.

 

Phase 2: Jan. 1, 2023

Price Comparison Tool for 500 Items and Services

Sanford Health Plan will release a web-based, self-service price comparison tool within our member portal. Members can also request a paper copy.

This tool empowers members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers. It covers 500 items and services.

Phase 3: Jan. 1, 2024

Enhanced Price Comparison Tool Covering All Items and Services

Sanford Health Plan will update our web-based price comparison tool within our member portal. Members can also request a paper copy.

This enhanced tool allows members to receive an estimate of their cost-sharing responsibility for any items or services from a specific provider or providers.

 

 

Machine Readable Files

Machine-readable-files in JSON format are provided below and updated monthly. Please reference the index file to navigate to the correct in-network-rates file for your needs. In-Network files will contain pricing information for covered items and services for in-network provider rates. Out-of-Network or the Allowed Amount file will contain historical payments to out-of-network providers for billed charges.

Disclaimer: The machine readable files below are made available in response to the federal Transparency in Coverage Rule. This material is not intended for consumer-friendly search of rates, benefits or cost-sharing. These files may be as large as one Terabyte (TB).

 

 

 

In-Network

Machine-Readable Files

 

 

Out-Of-Network Machine-Readable Files

 

 

To learn more, visit the Centers for Medicare & Medicaid Services information page or contact our customer service team at (800) 752-5863 from 8 a.m. to 5 p.m., Monday through Friday.