Price Transparency MRF Requirements

Verify compliance with the machine-readable files requirements

By Caroline Znaniec, MBA, MS-HCA, CRIP, CRCR, and Joe O’Malley, CHC

The Hospital Price Transparency Rule was implemented on January 1, 2021, and codified in the Code of Federal Regulations (Title 45, Subtitle A, Subchapter E, Part 180). CMS has finalised new changes to increase standardisation of the machine-readable files (MRF) to help deliver on the promise of hospital price transparency. Ensure that your hospital complies to enhance the public’s ability to access and aggregate information and streamline CMS’s ability to enforce the requirements.

*Reprinted with permission from New Perspectives, Journal of the Association of Healthcare Internal Auditors, Inc. Volume 43/ Number 2, 2024.

In response to industry members’ requests for standardisation in reporting, CMS developed a template and encoding requirements for the price transparency data elements. The CY2024 Outpatient Prospective Payment System (CY2024 Final Rule) published November 22, 2023, It’s 2024. Do Patients Know Where Your MRF Is? Verify compliance with the machine-readable files requirements By Caroline Znaniec, MBA, MS-HCA, CRIP, CRCR, and Joe O’Malley, CHC FEATURE provides guidance and related implementation (compliance) dates specific to the accessibility, format and structure, and content of the MRF. Exhibit 1 summarises the compliance dates, which vary by requirement and range from January of 2024 through January of 2025.

Exhibit 1 – Summary of compliance dates

Requirement

Regulation

Implementation (compliance) date

MRF Information

MRF Date

45 CFR 180.50(b)(2)(i)(B)

July 1, 2024

CMS Template Version

45 CFR 180.50(b)(2)(i)(B)

July 1, 2024

Hospital Information

Hospital Name

45 CFR 180.50(b)(2)(i)(A)

July 1, 2024

Hospital Location(s)

45 CFR 180.50(b)(2)(i)(A)

July 1, 2024

Hospital Address(es)

45 CFR 180.50(b)(2)(i)(A)

July 1, 2024

Hospital Licensure Information

45 CFR 180.50(b)(2)(i)(A)

July 1, 2024

Standard charges

Gross Charge

45 CFR 180.50(b)(2)(ii)

July 1, 2024

Discounted Cash

45 CFR 180.50(b)(2)(ii)

July 1, 2024

Payer Name

45 CFR 180.50(b)(2)(ii)(A)

July 1, 2024

Plan Name

45 CFR 180.50(b)(2)(ii)(A)

July 1, 2024

Standard Charge Method

45 CFR 180.50(b)(2)(ii)(B)

July 1, 2024

Payer-Specific Negotiated Charge – Dollar Amount

45 CFR 180.50(b)(2)(ii)(C)

July 1, 2024

Payer-Specific Negotiated Charge – Percentage

45 CFR 180.50(b)(2)(ii)(C)

July 1, 2024

Payer-Specific Negotiated Charge – Algorithm

45 CFR 180.50(b)(2)(ii)(C)

July 1, 2024

Estimated Allowed Amount

45 CFR 180.50(b)(2)(ii)(C)

January 1, 2025

De-identified Minimum Negotiated Charge

45 CFR 180.50(b)(2)(ii)

July 1, 2024

De-identified Maximum Negotiated Charge

45 CFR 180.50(b)(2)(ii)

July 1, 2024

Item and service information

General Description

45 CFR 180.50(b)(2)(iii)(A)

July 1, 2024

Setting

45 CFR 180.50(b)(2)(iii)(B)

July 1, 2024

Drug Unit of Measurement

45 CFR 180.50(b)(2)(iii)(C)

January 1, 2025

Drug Type of Measurement

45 CFR 180.50 (b)(2)(iii)(C)

January 1, 2025

Coding information

Billing/Accounting Code

45 CFR 180.50(b)(2)(iv)(A)

July 1, 2024

Code Type

45 CFR 180.50(b)(2)(iv)(B)

July 1, 2024

Modifiers

45 CFR 180.50(b)(2)(iv)(C)

January 1, 2025

Other new hospital price transparency requirements

Good faith effort

45 CFR 180.50(a)(3)(i)

January 1, 2024

Affirmation in the MRF

45 CFR 180.50(a)(3)(ii)

July 1, 2024

.txt file

45 CFR 180.50(d)(6)(i)

January 1, 2024

Footer link

45 CFR 180.50(d)(6)(ii)

January 1, 2024

 

Accessibility

As of January 1, 2024, a hospital must ensure that its MRF is easily accessible by both the public and by CMS for automated auditing. The new requirements include a .txt file and website footer. A hospital’s good faith effort in providing access to its MRF is demonstrated through meeting these requirements together with the publishing of the MRF itself. 

.txt file

The .txt file must be placed in the root folder of the website domain that hosts the MRF. The .txt file is a document that provides information specific to the hospital location name, source page URL that hosts the MRF, a direct link to the MRF, and designated point of contact information. To assist hospitals in generating the MRF, CMS provides instructions and a generator tool for document output.

Exhibit 2 – Example .txt file output

Image

While a health system may post multiple MRFs on its source page, all locations should be included in the single .txt file document.

Exhibit 3 − Example .txt file output with multiple locations

Image

When multiple locations (e.g., acute care hospital, stand-alone emergency center) share an MRF, a separate entry must be included in the output by location.

Exhibit 4 − Example .txt file output for shared MRF

Image

Where a hospital uses a vendor to host its MRF, the .txt file should indicate the vendor’s source page URL and the MRF URL established by the vendor. The point of contact should reflect the person or team of people that can answer questions regarding the publicly available MRF information.

Website footer

The hospital must provide a link in the footer of its website that is labeled exactly: “Price Transparency.” Other variations, such as “Pricing Transparency” or “Hospital Price Transparency,” are not acceptable. The footer must link directly to the publicly available webpage that hosts the link to the MRF.

Format and structure

As of July 1, 2024, hospital MRFs must conform to a CMS template layout. The compliance date applies to all hospitals, regardless of their use of prior voluntary templates or last annual update date. For example, if a hospital last updated its MRF in December of 2023, it must comply with the CMS template by July 1, 2024. Hospitals must continue to provide annual updates up to and after the required compliance dates.

CMS has published the template layout in three formats: CSV “Tall,” CVS “Wide,” and JSON. Hospitals may choose the format for publishing their charges. Within each format, CMS has adopted established standards and industry norms. The requirements include valid types by data element, such as string, date, Enum, numeric and Boolean. Values encoded incorrectly will generate a compliance deficiency. With each template format, CMS provides a README file that lists the valid types by data element, along with additional instructions.

Content

The content for the CMS MRF template resembles much of what has been in place since 2021. The content includes providing item and service descriptions, billing identifiers and standard charges, including gross and discounted cash prices and de-identified minimum and maximum charges. Under the CY2024 Final Rule, additional data elements are included to improve the public’s understanding of hospital provider and payer charge methodologies.

Steps for publicising your hospital charges using a required CMS template layout

  1. Identify your hospital and each hospital location that must make available its list of standard charges.
  2. Identify each standard charge your hospital has established and its corresponding item or service.
  3. Select a required CMS template.
  4. Gather and encode your standard charge information in the CMS template.
  5. Affirm the accuracy and completeness of your file.
  6. Name your MRF according to the CMS naming convention.
  7. Validate that you have encoded your data correctly within the CMS template.
  8. Post your machine-readable file prominently on a publicly available website.
  9. Add the .txt file and footer link.
  10. Update your hospital’s MRF annually.

Source: https://www.cms.gov/files/document/steps-machine-readable-file.pdf

 

The data elements provide information that contextualise the standard charges of the hospital. CMS categorises the data elements into five groups:

  1. MRF Information
  2. Hospital Information
  3. Standard charges
  4. Item and service information
  5. Coding information

Exhibit 5 summarises the new data elements as of July 1, 2024. An asterisk indicates a compliance date of January 1, 2025.

Exhibit 5 – New data elements

CategoryNew data element as of July 1, 2024 (Asterisk indicates required as of January 1, 2025)Definition and considerations
1. MRF informationMRF dateProvide the calendar date of the last file update.
CMS template versionCMS template version 2.0.0 is current as of May 2024.
Affirmation statementInclude a pre-populated statement, written and required by CMS, with a value encoded of “True” or “False” to confirm to the best of the hospital’s knowledge that the information provided is true, accurate and complete as of the date of the MRF.
2. Hospital informationHospital nameProvide the legal name of the hospital.
Hospital location(s)

Include the unique name of the hospital location(s), absent acronyms.

More than one hospital location is included when >1 location is included in the MRF. For example, under a single license a hospital and standalone emergency center share the same standard charges.

Hospital address(es)Disclose the geographic address of the corresponding locations.
Hospital licensure informationDisclose the hospital license and state/territory abbreviation. If the hospital does not have a license (e.g., state-owned hospitals), the field can be left blank. Hospitals without a license number, but with a registry number, may include the registry number as an option, but not required.
3. Standard Charges 
(Additional data elements including gross charge, discounted cash price, de-identified minimum and maximum charges remain unchanged and are required in the CMS template.)
Standard charge method

Provide the method used to establish the payer-specific negotiated charge.

Valid values include:

  • Case rate
  • Fee schedule
  • Per diem
  • Percent of total billed charges
  • Other
Payer-specific negotiated charge –   dollar amount

Disclose the charge that a hospital has negotiated with a third-party payer for the corresponding item or service.

The value is expressed as a dollar amount without dollar signs or cents when the cents are “00.”

Payer-specific negotiated charge – percentage

Complete this when a payer-specific negotiated charge has been established as a percentage and no dollar amount can be calculated. For example, when the negotiated charge is based on the aggregation of charges that may vary by patient (e.g., inpatient stay, surgical procedure).

The percentage is provided as a numeric representation and not as a decimal. For example, 65.5 percent is to be entered as 65.5 and not .655.

An estimated allowed amount must also be calculated when this type of negotiated charge is encoded.

Payer-specific negotiated charge – algorithm

Disclose the expressed algorithm that the hospital has negotiated. For example, the adjusted base payment rate indicated in the standard charge/negotiated dollar data element may be further adjusted for additional factors including transfers and outliers.

An estimated allowed amount must also be calculated when this type of negotiated charge is encoded.

Estimated allowed amount*

Provide the average dollar amount that the hospital has historically received from a third-party payer for an item or service.

If historic claims history is insufficient to derive the estimated allowed amount, the hospital should encode 999999999 (nine 9s) in the data element value.

Additional generic notesUse free text data to explain any of the data, including, for example, blanks due to no applicable data, charity care policies, or other contextual information that aids in the understanding of the standard charges.
Additional payer-specific notesUse free text data to explain data in the file that is related to a payer-specific negotiated charge.
4. Item and service information 
(The General Description data element remains unchanged from prior requirements and is required in the CMS template.)
Setting

Provide Information that indicates the setting of the item or service.

Valid values include:

  • Inpatient
  • Outpatient
  • Both
Drug unit of measure*

Indicate the unit value that corresponds to the established standard charge.

For example, an 81mg aspirin unit of measure would be indicated as 1.

Drug type of measurement*

Disclose the measurement type that corresponds to the established standard charge for drugs as defined by either the National Drug Code or the National Council for Prescription Drug programmes. 
The measurement aligns to volume measurement and may not correspond with HCPCS (e.g., J-Code) billable units.

Valid values include:

  • GM or GR (grams)
  • ME (milligrams)
  • ML (milliliters)
  • UN (unit)
  • F2 (international unit)
  • EA (each)

For example, an 81mg aspirin type of measurement would be indicated as UN.

5. Coding informationBilling/accounting code

The code(s) are used by the hospital for purposes of billing or accounting for the item or service.

Billing/accounting code greater than one may be associated with an item or service. For example, a payer may require the combination of a revenue code and CPT code for reimbursement.

Code type

to indicate the type of code displayed. Valid values include, but are not limited to:

  • CPT
  • HCPCS
  • NDC
  • MS-DRG
  • RC
Modifiers*

Provide any modifier(s) that may change the standard charge that corresponds to hospital items or services. 

Payment modifiers may include:

  • Prolonged service−22
  • Bilateral procedure−50
  • Reduced service−52
  • Staged procedure−58

CMS has provided examples of how to complete the CMS template based on common scenarios and continues to add to the scenarios as providers reach out with questions and request further guidance.

CMS scenario examples

Exhibits 6–10 provide examples of CMS scenarios. The data has been transposed from CSV Tall format for illustrative purposes and includes only those data elements with values.

Exhibit 6 – Case rate based on a MS-DRG algorithm

Category

Description

description

Major hip and knee joint replacement or reattachment of lower extremity without mcc

code|1

470

code|1|type

MS-DRG

code|2

175869

code|2|type

LOCAL

setting

inpatient

payer_name

Platform Health Insurance

plan_name

PPO

standard_charge|negotiated_dollar

20000

standard _charge|negotiated_algorithm

The adjusted base payment rate indicated in the standard charge or negotiated dollar data element may be further adjusted for additional factors including transfers and outliers.

estimated_amount

22243.34

standard_charge|methodology

case rate

standard_charge|min

20000

standard_charge|max

20000

 

Exhibit 7 – Percent of total billed charges

Category

Description

description

Major hip and knee joint replacement or reattachment of lower extremity without mcc

code|1

470

code|1|type

MS-DRG

code|2

175869

code|2|type

LOCAL

setting

inpatient

payer_name

Region Health Insurance

plan_name

HMO

standard_charge|negotiated_percentage

50

estimated_amount

23145.98

standard_charge|methodology

Percent of total billed charges

standard_charge|min

20000

standard_charge|max

20000

 

Exhibit 8 – Fee schedule: Standard charge is a percent of a common fee schedule and the standard charge dollar amount can be calculated

Category

Description

description

Evaluation of hearing function to determine candidacy for, or postoperative status of, surgically implanted hearing device; first hour

code|1

92626

code|1|type

CPT

code|1|type

outpatient

standard_charge|gross

150

standard_charge|discounted_cash

125

payer_name

Platform Health Insurance

plan_name

PPO

standard_charge|negotiated_dollar

98.98

standard_charge|methodology

fee schedule

standard_charge|min

98.98

standard_charge|max

98.98

additional_generic_notes

110% of the Medicare fee schedule

 

Exhibit 9 – Fee schedule where the standard charge is a percent of a common fee schedule, and the standard charge dollar amount cannot be calculated

Category

Description

description

Evaluation of hearing function to determine candidacy for, or postoperative status of, surgically implanted hearing device; first hour

code|1

92626

code|1|type

CPT

setting

outpatient

standard_charge|gross

150

standard_charge|discounted_cash

125

payer_name

Region Health Insurance

plan_name

HMO

standard_charge|negotiated_percentage

115

estimated_amount

105.34

standard_charge|methodology

fee schedule

standard_charge|min

98.98

standard_charge|max

98.98

additional_generic_notes

115% of the state's workers' compensation amount

 

Exhibit 10 – Per diem where the standard charges are for a length of stay of 1– 3 days

Category

Description

description

Behavioral health; residential (hospital residential treatment programme), without room and board, per diem, days 1–3

code|1

H0017

code|1|type

HCPCS

setting

inpatient

standard_charge|gross

2500

standard_charge|discounted_cash

2250

payer_name

Region Health Insurance

plan_name

HMO

standard_charge|negotiated_dollar

2000

standard_charge|methodology

per diem

standard_charge|min

2000

standard_charge|max

2000

 

Exhibit 11 – Per diem where the standard charges are for a length of stay of 4–5 days

Category

Description

description

Behavioral health; residential (hospital residential treatment programme), without room and board, per diem, days 4–5

code|1

H0017

code|1|type

HCPCS

setting

inpatient

standard_charge|gross

2500

standard_charge|discounted_cash

2250

payer_name

Region Health Insurance

plan_name

HMO

standard_charge|negotiated_dollar

1800

standard_charge|methodology

per diem

standard_charge|min

1800

standard_charge|max

1800

standard_charge|max

98.98

Noncompliance risks are high for hospitals that do not meet accessibility requirements and publish an MRF in the required format.

Audit programme considerations

Hospitals at the highest risk of noncompliance include those that do not meet accessibility requirements or do not publish a machine-readable file in the required CMS template format. In establishing your audit work programme for hospital price transparency, you can leverage CMS’ resources (see sidebar) to understand the full requirements and to align your testing with the highest risks. Further audit steps should include interviews of those stakeholders responsible for both compiling the MRF content and formatting to the new required structure.

Testing should include a comparison to payer contract and reimbursement terms, as well as reconciliation of the chargemaster and other modules that may house charge detail (e.g., room and board tables, pharmacy formularies, supply item masters).

Testing provides confidence in affirming to CMS that “To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.”

Resources


Conclusion

Despite challenges and resistance by hospitals, CMS has doubled down on requirements to make MRFs easier to find and use. By working toward pricing transparency compliance, hospitals reduce the risk of monetary fines, public scrutiny and reputational damage, while potentially uncovering charge capture opportunities and increasing the quality and efficiency of their revenue cycle processes. Help your hospitals gain these advantages.

I would rather work with five people who really believe in what they are doing ... than five hundred who can't see the point.
Patrick Dixon, business consultant
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