Solutions for Transparency in Coverage

The Department’s guidelines on ensuring transparency in coverage are quite elaborate on the context and objective of disclosing information. Our previous blogs outline the disclosure requirements for both the Participants, Beneficiaries, or Enrollees, and the public.

However, when disclosure requirements are converted into solutions, complexities arise. Currently, health plans do not have the required information in one place. Even if they do, their Enterprise Data Warehouse (EDW) would have been developed by keeping the previous compliance requirements, reporting, analytics, extracts, etc. in consideration.

Here’s how health plans can adhere to disclosure requirements to their Participants, Beneficiaries, or Enrollees.

Self-service Tool

As the name suggests, members can use the tool themselves to identify the cost of service for one or many providers. Member will be able to see the information in codes, such as ICD, CPT, NDC, etc. Additionally, members can use the description of service as an input parameter.

A viable solution would be the enhancement of the existing member portal used by health plans. Logic authentication will automatically confirm whether a member is active or not.

To display the required information to members, their eligibility, plan details, provider contracts within the plan, and their historical claim information are necessary.

Identifying the Provider and Cost-negotiation

When a member searches for a service, initially, it needs to identify if the service is covered under the plan or not. Health plans can restrict the search to the covered services, by identifying the member login.

If the service is covered, the tool will look for in-network providers within the member’s proximity. Once the provider is identified, the tool will look for the negotiation details corresponding to said service. When the negotiation cost for the service is available, the tool will move to the next calculation. When it is not, the tool will fetch the negotiation cost, and carry out calculations if required, before displaying them.

Example logics are already built into multiple CMS Reference pricing tables. Based on the contract, plans would pay 80% of the amount defined by CMS Reference pricing.

Fetching Cost-sharing Details

Once the negotiated cost is identified, the tool will fetch the member’s share of co-pay, co-insurance, and deductible for the current policy year. The member may not have reached their deductible limit of the year, yet. If the service cost is less than the deductible amount, members must pay the whole amount themselves.

Next, the actual amount which members need to pay gets calculated. The tool displays the service codes, description of service, co-pay, co-insurance, the deductible amount for the service, and details of the providers. Usually, health plans have a flat maximum amount for each service for when members avail services from out-of-network providers. As plans may not have details of all out-of-network providers, the tool would show only one amount irrespective of the provider.

Hard Copy Form 

Health plans must provide hard copy forms with the requested information for the member population that does not have access to internet services or cannot operate the online tool. The objective is to develop a mechanism for members to request information via various mediums such as emails, calls to customer service, etc.

Instead of building a process from scratch for the hard copy form delivery, payers could integrate additional functionality into the self-service tool. The added functionality can enable employees to access the tool via separate internal logins.

When a member calls or sends an email to inquire about a service, the payers can start by searching the member ID on the tool to verify if the member’s plan is active or not. The tool must be able to capture the member’s address from their profile or allow payers to input the requested address. This is a requirement since the results must have the distance of the provider’s location from the member’s.

In short, payers can utilize their self-service tool to carry out paper form requests since the information requested is the same in both scenarios, except for the delivery method.  But it is highly unlikely that existing solutions can capture and record the dates of the request being received and fulfilled.

According to the Transparency in Coverage rule, health plans must dispatch the response within 2 business days of receiving the request. To ensure compliance, the solution must capture both dates and raise a flag if the request is not processed within the stipulated time.

What we can do  

These solutions to ensure compliance may look easy, but there goes a lot of time, effort, and diligence to align the existing systems and processes with the conditions of the disclosure requirements.

Connect with us at, and let us discuss how we can help you to be compliant with the Transparency in Coverage rule with effective and efficient solutions.

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Pankaj Kundu

Pankaj Kundu

Pankaj has vast experience ranging from claims processing engine to application of machine learning algorithms in US Healthcare. As a Healthcare Business Analyst, he is passionate about addressing healthcare data/process related challenges and ideating solutions for clients.
Pankaj Kundu

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