CMS Price Transparency Rule Guidance for Hospitals

As of January 1, 2021 in accordance with the US Government Centers for Medicare and Medicaid Services (CMS) Hospital Price Transparency Rule all US hospitals are obligated to make public their standard charges online in two formats: Price Transparency File and Shoppable Services. Both lists are required by CMS subject to penalties.Please find the key points to help hospitals verify that their price transparency and shoppable service files meet all CMS requirements:

Price Transparency File
GENERAL REQUIREMENTS a complete overview at Subpart B-Public Disclosure Requirements):	Single comprehensive machine-readable file containing a list of standard charges, as applicable, for all items and services (please refer to 45 CFR § 180.20); Includes both individual items and service packages provided to either an inpatient or an outpatient; Must Include both hospital services and physician/professional fees if employed by the hospital.

STANDARD CHARGES: The following data points (columns) are required for each charge item.	Gross charge -price transparency rate typically the list rate; Discounted cash price – price for those who personally pay for services; Payer-specific negotiated charges – applies to all third-party* payers other than Medicare and Medicaid free-for-service. All direct negotiated charges should be included (also excludes WC and VA if non-negotiated); De-identified minimum negotiated charge; De-identified maximum negotiated charge.
	*Defining third-party payer – if a hospital has negotiated with an employer for particular services. Inclusion of charges for “employed” physicians CMS declines to codify a definition for employment”. Physician charges may be elsewhere within hospital accounting and billing system or in contracts/rate sheets with third party payers.

Description of item or service and billing codes	A description of each item or service along with the code(s) used by the hospital for purposes of accounting or billing for the item or service.
	Common billing or accounting code(s): Include any code used by your hospital for purposes of accounting or billing for the item or service, including, but not limited to, the CPT code, the HCPCS code, the DRG, or other used payer identifier. Corresponding common billing and accounting codes must be included. Please refer to Table 1 84 FR 65558 for an example of a display of gross charges which includes this scenario.

Service not offered by hospital	No requirement

Format	A single digital file that is machine-readable file. Formats include .XML, .JSON, .CSV (but not limited to). .PDF is NOT a machine readable format.

Naming Convention	Template: <ein>_<hospital-name>_standardcharges.[json\|xml\|csv] EIN – Employer Identification Number of the hospital Write out “standardcharges” as a single word, without capitalization; Finish by using the .json, .xml, or .csv as applicable to the file format you have chosen; Separate the EIN, hospital name, and ‘standardcharges’ by using an underscore: 12345678_example-hospital-name_standardcharges.csv In addition, hospitals may do the following: Exclude dashes from the EIN (use “12345678”, not “12-345678”) Use the legal name of the hospital without capitalization and include dashes between words (use “example-hospital-name”, not “Example Hospital Name”)

Location of Information	Displayed prominently on a publicly available website and in a prominent manner that clearly identifies the hospital location with which the information is associated.

Access to information	No barriers to access: Free of charge, no account or password required; No Protected Health Information required to access No submission of any Personal Identifying Information.

Search Capability	Digitally searchable

Updates	Annually – with date of last update clearly indicated

For additional details on this requirement refer to:	45 CFR §180.50.

Shoppable Services
GENERAL REQUIREMENTS a complete overview at Subpart B-Public Disclosure Requirements):	Shoppable services are defined as services that can be scheduled by a health care consumer in advance; Must include standard charges for at least 300 shoppable services or bundles (or as many as the hospital provides if less than 300), including corresponding ancillary services (84 FR 65564), if applicable, that are provided by the hospital; Must include 70 specific bundles identified by CMS (Table 3, 84 FR 65571) – provider must have total of at least 300 even if not all 70 are offered at facility; Services selected for display should be those commonly provided to your hospital`s patients; Consumer-friendly display; Easily searchable; If a hospital does not provide 300 shoppable services, the hospital must make public its standard charges for as many shoppable services as it provides; Please refer to 84 FR 65569 and 65574 for further discussion;

STANDARD CHARGES: The following data points (columns) are required for each charge item.	Discounted cash price or gross charge, where the hospital has not established a discounted cash price) Payer-specific negotiated charges applies to all third-party payers other than Medicare and Medicaid free-for-service. All direct negotiated charges should be included (also excludes WC and VA if non-negotiated); De-identified minimum negotiated charge; De-identified maximum negotiated charge.
	*Defining third-party payer – if a hospital has negotiated with an employer for particular services. Inclusion of charges for “employed” physicians CMS declines to codify a definition for employment”. Physician charges may be elsewhere within hospital accounting and billing system or in contracts/rate sheets with third party payers.

Description of item or service and billing codes	A plain-language description of each shoppable service along with any primary code used by the hospital for purposes of accounting or billing for the shoppable service.
	Common billing or accounting code(s): Include any code used by your hospital for purposes of accounting or billing for the item or service, including, but not limited to, the CPT code, the HCPCS code, the DRG, or other used payer identifier. Corresponding common billing and accounting codes must be included. Please refer to Table 1 84 FR 65558 for an example of a display of gross charges which includes this scenario.

Service not offered by hospital	Use an indicator when one or more of the CMS-specified shoppable services are not offered by the hospital (for example, N/A)

Format	No requirement

Naming Convention	No requirement

Location of Information	Displayed prominently on a publicly available website and in a prominent manner that clearly identifies the hospital location with which the information is associated.

Access to information	No barriers to access: Free of charge, no account or password required; No Protected Health Information required to access No submission of any Personal Identifying Information.

Search Capability	Searchable by service description, billing code, and payer

Updates	Annually – with date of last update clearly indicated

For additional details on this requirement refer to:	45 CFR §180.60

	Price Transparency File Download ideal example Download ideal template	Shoppable Services Download ideal example Download ideal template
GENERAL REQUIREMENTS a complete overview at Subpart B-Public Disclosure Requirements):	Single comprehensive machine-readable file containing a list of standard charges, as applicable, for all items and services (please refer to 45 CFR § 180.20); Includes both individual items and service packages provided to either an inpatient or an outpatient; Must Include both hospital services and physician/professional fees if employed by the hospital.	Shoppable services are defined as services that can be scheduled by a health care consumer in advance; Must include standard charges for at least 300 shoppable services or bundles (or as many as the hospital provides if less than 300), including corresponding ancillary services (84 FR 65564), if applicable, that are provided by the hospital; Must include 70 specific bundles identified by CMS (Table 3, 84 FR 65571) – provider must have total of at least 300 even if not all 70 are offered at facility; Services selected for display should be those commonly provided to your hospital`s patients; Consumer-friendly display; Easily searchable; If a hospital does not provide 300 shoppable services, the hospital must make public its standard charges for as many shoppable services as it provides; Please refer to 84 FR 65569 and 65574 for further discussion;

STANDARD CHARGES: The following data points (columns) are required for each charge item.	Gross charge -price transparency rate typically the list rate; Discounted cash price – price for those who personally pay for services; Payer-specific negotiated charges – applies to all third-party* payers other than Medicare and Medicaid free-for-service. All direct negotiated charges should be included (also excludes WC and VA if non-negotiated); De-identified minimum negotiated charge; De-identified maximum negotiated charge.	Discounted cash price or gross charge, where the hospital has not established a discounted cash price) Payer-specific negotiated charges applies to all third-party payers other than Medicare and Medicaid free-for-service. All direct negotiated charges should be included (also excludes WC and VA if non-negotiated); De-identified minimum negotiated charge; De-identified maximum negotiated charge.
	*Defining third-party payer – if a hospital has negotiated with an employer for particular services. Inclusion of charges for “employed” physicians CMS declines to codify a definition for employment”. Physician charges may be elsewhere within hospital accounting and billing system or in contracts/rate sheets with third party payers.

Description of item or service and billing codes	A description of each item or service along with the code(s) used by the hospital for purposes of accounting or billing for the item or service.	A plain-language description of each shoppable service along with any primary code used by the hospital for purposes of accounting or billing for the shoppable service.
	Common billing or accounting code(s): Include any code used by your hospital for purposes of accounting or billing for the item or service, including, but not limited to, the CPT code, the HCPCS code, the DRG, or other used payer identifier. Corresponding common billing and accounting codes must be included. Please refer to Table 1 84 FR 65558 for an example of a display of gross charges which includes this scenario.

Service not offered by hospital	No requirement	Use an indicator when one or more of the CMS-specified shoppable services are not offered by the hospital (for example, N/A)

Format	A single digital file that is machine-readable file. Formats include .XML, .JSON, .CSV (but not limited to). .PDF is NOT a machine readable format.	No requirement

Naming Convention	Template: <ein>_<hospital-name>_standardcharges.[json\|xml\|csv] EIN – Employer Identification Number of the hospital Write out “standardcharges” as a single word, without capitalization; Finish by using the .json, .xml, or .csv as applicable to the file format you have chosen; Separate the EIN, hospital name, and ‘standardcharges’ by using an underscore: 12345678_example-hospital-name_standardcharges.csv In addition, hospitals may do the following: Exclude dashes from the EIN (use “12345678”, not “12-345678”) Use the legal name of the hospital without capitalization and include dashes between words (use “example-hospital-name”, not “Example Hospital Name”)	No requirement

Location of Information	Displayed prominently on a publicly available website and in a prominent manner that clearly identifies the hospital location with which the information is associated.

Access to information	No barriers to access: Free of charge, no account or password required; No Protected Health Information required to access No submission of any Personal Identifying Information.

Search Capability	Digitally searchable	Searchable by service description, billing code, and payer

Updates	Annually – with date of last update clearly indicated

For additional details on this requirement refer to:	45 CFR §180.50.	45 CFR §180.60

Please note, beginning January 1, 2021, CMS will monitor and enforce these price transparency requirements. For hospitals that do not comply:

they may be issued a warning notice by CMS
after receiving a warning notice, CMS will request a corrective action plan,
CMS may impose a civil monetary penalty of up to $5,500 per day for non-compliance:

Daily Cost for Non-Compliance –
30 beds or less = $300 per day
31-550 beds = $10 per bed/per day
551 beds+ = $5,500 per day

Annual Cost for Non-Compliance –
30 beds or less = $109,500
31-500 beds = $113,150-$2,007,500
551 beds+ = $2,007,500

For additional details on monitoring and enforcement refer to 45 CFR Subpart C
and for information on appealing a civil monetary penalty refer to 45 CFR Subpart D.

Resources:

Price Transparency File

GENERAL REQUIREMENTS

STANDARD CHARGES:

Description of item or service and billing codes

Service not offered by hospital

Format

Naming Convention

Location of Information

Access to information

Search Capability

Updates

For additional details on this requirement refer to:

Shoppable Services

GENERAL REQUIREMENTS

STANDARD CHARGES:

Description of item or service and billing codes

Service not offered by hospital

Format

Naming Convention

Location of Information

Access to information

Search Capability

Updates

For additional details on this requirement refer to:

Price Transparency File

Shoppable Services

GENERAL REQUIREMENTS

STANDARD CHARGES:

Description of item or service and billing codes

Service not offered by hospital

Format

Naming Convention

Location of Information

Access to information

Search Capability

Updates

For additional details on this requirement refer to:

Need help getting started or have more questions? Fill out the form below and a member of our team will contact you.