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

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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.

*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

Download ideal example

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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.

*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.

*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 requirementUse 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 searchableSearchable 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

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