CMS TiC Specifications

Transparency in Coverage
Evolution of Required MRF Data Elements

A chronological guide to how insurer Transparency in Coverage MRF data requirements have expanded from the original rule through Schema 2.0 and the 2025 proposed changes. Explore the definitions and regulatory history of each required element.

touch_app Tap or click any element name to reveal its definition and why it matters.

On smaller screens, scroll the comparison sideways to view all periods.

Insurer MRF data elements across final-rule and proposed periods. Open a data element to read its definition and why it matters.
Data Element Original Rule Eff. Jul 2022 Schema 1.x Updates 2023–24 Schema 2.0 Eff. Feb 2026 2025 Proposed Rule Pending
REPORTING ENTITY
Reporting Entity Name
The legal name of the health plan or insurance issuer publishing the machine-readable file.
Why it matters: Identifies which insurer or self-funded plan the pricing data belongs to, essential for matching data to your specific coverage.
 Introduced check check check
Reporting Entity Type
Whether the entity is a "health insurance issuer" (like Aetna or BCBS) or a "group health plan" (employer-sponsored).
Why it matters: Determines which regulatory requirements apply and helps users understand who is responsible for the data.
 Introduced check check check
Plan Name
The specific insurance product name, such as "Gold PPO 500" or "Silver HMO."
Why it matters: Rates vary dramatically between plans from the same insurer. This tells you exactly which plan the negotiated rates apply to.
 Introduced check check check
Plan ID
A unique identifier for the plan — either an EIN (Employer Identification Number) or HIOS ID (Health Insurance Oversight System ID).
Why it matters: Enables precise matching of pricing data to a specific plan, especially important when plan names are similar or reused across products.
 Introduced check check check
Plan ID Type (EIN/HIOS)
Indicates whether the Plan ID is an EIN (used for employer-sponsored plans) or a HIOS ID (used for marketplace plans).
Why it matters: Without knowing the ID type, the plan ID number alone is ambiguous. This field ensures correct interpretation.
 Introduced check check check
Plan Market Type
Whether the plan is sold on the "group" market (employer-sponsored) or the "individual" market (ACA marketplace or direct purchase).
Why it matters: Group and individual plans often have very different negotiated rates for the same services. This distinction is key for accurate analysis.
 Introduced check check check
Last Updated On
The date when the machine-readable file was last refreshed or modified.
Why it matters: Tells researchers and consumers how current the data is. Stale data can lead to incorrect cost estimates.
 Introduced check check check
Version
The schema version of the machine-readable file format (e.g., "1.0.0" or "2.0.0").
Why it matters: Different versions have different fields and structures. Software parsing the files must know the version to interpret data correctly.
 Introduced check check check
IN-NETWORK RATE DATA
Negotiation Arrangement
The type of payment model: fee-for-service (FFS), bundled payment, or capitation (fixed payment per patient per period).
Why it matters: The payment model fundamentally changes how to interpret the rate. A $500 FFS rate means something very different from a $500 capitated rate.
 Introduced check check check
Service Name
A human-readable name for the medical service, such as "Office Visit - Established Patient" or "MRI Brain Without Contrast."
Why it matters: Makes the data accessible to non-experts. Without this, users would need to look up every billing code to understand what service is being priced.
 Introduced check check check
Billing Code
The standardized code identifying a specific medical service — like CPT 99213 (office visit) or NDC codes for drugs.
Why it matters: Billing codes are the universal language for comparing the same service across different insurers and providers.
 Introduced check check check
Billing Code Type
The coding system the billing code comes from: CPT, HCPCS, NDC, MS-DRG, APC, ICD, and 11 other recognized types.
Why it matters: A code number only has meaning within its coding system. "99213" is a CPT code for an office visit but could mean something else in another system.
 Introduced check check check
Billing Code Type Version
The specific year or edition of the coding system being referenced (e.g., "2024" for the 2024 CPT code set).
Why it matters: Codes change meaning between versions. A code that meant one thing in 2020 might have been revised or retired in 2024.
 Introduced check check check
Description
A detailed textual description of the billed service, often drawn from the official code description.
Why it matters: Provides the full clinical detail that short service names cannot capture, enabling precise understanding of what is being priced.
 Introduced check check check
Bundled Codes
When the negotiation arrangement is "bundle," this lists all the individual billing codes included in the bundled payment.
Why it matters: Bundled payments cover multiple services at once. Without knowing what is included, you cannot compare a bundle price to individual service prices.
 Introduced check check check
Covered Services
For capitation arrangements, the list of services covered under the fixed per-member-per-month (PMPM) payment.
Why it matters: Capitation pays one rate for all covered services. This field reveals exactly which services are included in that fixed payment.
 Introduced check check check
NEGOTIATED PRICE DETAILS
Negotiated Type
How the rate was determined: "negotiated" (directly agreed), "derived" (calculated from a formula), "fee schedule" (standard price list), "percentage" (% of a reference), or "per diem" (daily rate).
Why it matters: The type determines how to interpret the dollar amount. A "percentage" of 150 means 150% of Medicare, not $150.
 Introduced check check check
Negotiated Rate
The actual dollar amount or percentage that the insurer has agreed to pay the provider for this service.
Why it matters: This is the core data point — what insurers actually pay providers. It reveals the true cost of healthcare behind the scenes.
 Introduced check check check
Expiration Date
The date when the negotiated rate agreement expires and would need to be renegotiated.
Why it matters: Helps users understand how long a rate is locked in. Expired rates may no longer reflect current payment amounts.
 Introduced check check check
Billing Class
Whether the rate applies to "professional" services (physician fees) or "institutional" services (facility fees), or "both."
Why it matters: Patients often receive two bills for one visit — one from the doctor (professional) and one from the hospital (institutional). This clarifies which is which.
 Introduced check check check
Setting (Inpatient/Outpatient)
Whether the negotiated rate applies to inpatient care (admitted overnight), outpatient care (same-day), or both.
Why it matters: The same procedure can cost dramatically different amounts depending on the care setting. Schema 2.0 makes this distinction explicit.
 — — Introduced check
Service Code
Place-of-service codes (like "11" for office or "21" for inpatient hospital) that further specify where the service was delivered.
Why it matters: Provides granular location context beyond just inpatient/outpatient. A procedure in a doctor's office vs. an ASC vs. a hospital may have different rates.
 Introduced check check check
Billing Code Modifier
Two-character modifier codes (like "-26" for professional component or "-TC" for technical component) that alter how a billing code is interpreted.
Why it matters: Modifiers change the price. An X-ray billed with modifier -26 (reading only) costs less than the full X-ray with both technical and professional components.
 Introduced check check check
Additional Information
Free-text field for supplementary details about the negotiated rate that do not fit into other structured fields.
Why it matters: Captures nuances like volume discounts, seasonal adjustments, or special contract terms that affect pricing but have no dedicated field.
 Introduced check check check
PROVIDER IDENTIFICATION
Provider Group ID
A unique reference number linking negotiated rates to a specific group of providers. Introduced in Schema 1.x to enable deduplication.
Why it matters: Before this, the same provider appeared hundreds of times across different services, inflating file sizes to terabytes. This ID allows storing provider info once and referencing it many times.
 — Introduced check check
National Provider Identifier(s)
The 10-digit NPI number(s) assigned to individual healthcare providers or organizations that have agreed to the negotiated rate.
Why it matters: NPIs are the standard way to identify specific doctors, clinics, and hospitals. This lets you look up exactly which providers accept the negotiated rate.
 Introduced check check check
Tax Identification Number
The TIN (either an EIN or individual NPI) of the billing entity — the organization or individual that submits claims for payment.
Why it matters: TINs identify who gets paid. Multiple NPIs (individual doctors) often bill under one TIN (their practice group), and knowing this relationship is crucial for network analysis.
 Introduced check check check
TIN Type (EIN/NPI)
Whether the Tax Identification Number is an EIN (Employer Identification Number for organizations) or an NPI (for individual practitioners).
Why it matters: Distinguishes between organizational and individual billing entities, which matters for understanding practice structures and payment flows.
 Introduced check check check
TIN Business Name
The registered business name associated with an EIN-type TIN, such as "Springfield Medical Group LLC."
Why it matters: Without the business name, an EIN is just a number. This field makes provider organizations identifiable without external database lookups.
 — — Introduced check
Network Name
The name of the provider network (e.g., "Blue Choice PPO Network" or "Preferred Provider Network") to which the negotiated rate belongs.
Why it matters: Insurers maintain multiple networks with different rates. This field tells you which specific network a rate applies to, critical for accurate cost estimates.
 — — Introduced check
OUT-OF-NETWORK DATA
Billed Charge
The amount an out-of-network provider originally billed the insurer for a service before any adjustments or negotiations.
Why it matters: Shows the full price out-of-network providers charge, revealing the gap between what they bill and what insurers actually pay.
 Introduced check check check
Allowed Amount
The dollar amount the insurer paid or approved for the out-of-network service, after applying its payment policies.
Why it matters: Shows how an out-of-network claim was valued compared with the billed charge. The difference is not automatically the patient's responsibility; balance-billing protections may apply.
 Introduced check check check
Out-of-Network Provider NPIs
The NPI numbers of the out-of-network providers who delivered the service. Only reported when at least 20 claims exist (privacy threshold).
Why it matters: Identifies specific OON providers, but only when there are enough claims to prevent re-identification of individual patients from small samples.
 Introduced check check check
OON TIN (Type & Value)
The Tax Identification Number of the out-of-network billing entity, with its type (EIN or NPI).
Why it matters: Identifies the billing organization for OON services, enabling analysis of which entities frequently bill out-of-network.
 Introduced check check check
OON Service Code
The place-of-service code for out-of-network claims, indicating where the service was delivered.
Why it matters: OON costs vary by setting. Emergency room OON charges are typically much higher than office-based OON charges.
 Introduced check check check
OON Billing Class
Whether the out-of-network charge is for "professional" (physician) or "institutional" (facility) services.
Why it matters: Separates the two components of OON billing, enabling analysis of whether high OON costs are driven by facility fees, physician fees, or both.
 Introduced check check check
CLINICAL & SEVERITY
Severity of Illness (DRGs)
For DRG-based negotiated rates, the severity of illness level (e.g., minor, moderate, major, extreme) that affects the payment amount.
Why it matters: DRG payments vary dramatically by severity. A pneumonia case with complications pays much more than a simple pneumonia. Without severity, DRG-based rates are misleading.
 — — Introduced check
CONSUMER PRICE TOOL (RELATED REQUIREMENTS)
500 Shoppable Items
Plans were first required to offer a consumer-facing price comparison tool for at least 500 common shoppable services by January 1, 2023.
Why it matters: The first step toward consumer price shopping. These 500 items cover the most common procedures patients might plan and shop for in advance.
 — Introduced check check
All Shoppable Items
By January 1, 2024, the price comparison tool must cover all shoppable items and services, not just the initial 500.
Why it matters: Expanded consumer access to cost information for every plannable medical service, enabling true price shopping across the full range of healthcare.
 — — Introduced check
Phone Cost-Sharing Disclosure
The proposal would require plans to provide the same cost-sharing information by phone upon request as their online transparency tools disclose.
Why it matters: Members who cannot use the online tool could request comparable information by phone. This proposal builds on existing phone-access requirements.
 — — — Proposed
PROPOSED NEW REQUIREMENTS
MRF Location File
A proposed plain-text file in the root of a payer's website identifying where its machine-readable files are hosted and who to contact about them.
Why it matters: Finding the right MRF among many files can be difficult. A standardized location file would make automated discovery easier.
 — — — Proposed
Utilization Data Files
Proposed new files reporting actual service utilization volumes (how many times each service was used) alongside the negotiated rates.
Why it matters: Rates alone do not tell the full cost story. Combining rates with utilization volumes enables true total-cost-of-care analysis and meaningful plan comparisons.
 — — — Proposed
Change Log Files
Proposed mandatory files documenting what changed between each version of the MRFs, including added, removed, and modified rates.
Why it matters: Processing multi-terabyte files from scratch every month is impractical. Change logs enable efficient incremental updates, saving enormous computational resources.
 — — — Proposed
Quarterly Reporting Cadence
Proposed shift from monthly MRF updates to quarterly updates, reducing the publication frequency from 12 to 4 times per year.
Why it matters: Monthly updates created excessive compliance burden with minimal benefit, since most negotiated rates do not change monthly. Quarterly balances freshness with practicality.
 — — — Proposed
Footer Link Requirement
Proposed requirement for plan websites to include a "Price Transparency" link in their footer, directing members to the MRF hosting page.
Why it matters: Many plans technically comply by burying their tools in hard-to-find locations. A mandatory footer link ensures consumers can actually find the pricing information.
 — — — Proposed
Introduced Element first required in this rule
Proposed Element proposed (pending final rule)
Continues to be required
Not yet required
Note: Plans posting their February 2026 monthly MRFs on or after February 2, 2026 should use Schema 2.0. The 2025 Proposed Rule (CMS-9882-P) is shown last to distinguish proposals from current requirements; its comment period closed on March 2, 2026. The consumer price-tool rows describe related disclosure obligations, not MRF data fields. For authoritative requirements and updates, see CMS Schema 2.0 guidance and the CMS proposal fact sheet.