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 AccessSanford 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.
Sanford Health Plan members can log in to their member portal within MyChart, view the “Insurance” section and choose “Shopping Tool” from the menu. To view a complete list of the 500 items and services featured in the tool, visit this webpage.
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).
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.