CMS TiC Specifications
Transparency in Coverage
Evolution of Required MRF Data Elements
Explore payer MRF specifications and the October 2026 final rule. Finalized changes have future applicability dates; they are not all current obligations.
What applies, and when?
Reviewed November 3, 2026. The final rule published October 6, 2026 is effective December 7, 2026. Existing requirements continue until the applicable transition dates.
- March 6, 2027: amendments to in-network and out-of-network disclosures apply. Quarterly posting starts April 1, 2027.
- September 6, 2027: contextual-file provisions and the website footer requirement apply. Initial taxonomy and text-file posting follows on October 1, 2027.
- July 1, 2028: annual utilization-file posting begins under its separate timing provision.
- Plan or policy years beginning on or after January 1, 2027: self-service-tool amendments apply.
The proposed change-log file and numerical enrollment totals were not finalized. The CMS summary explains the changes; the final rule supplies the detailed timing provisions.
The table summarizes selected data elements and related obligations, not an exhaustive implementation specification. Schema releases and legal applicability dates are distinct. For source selection, read hospital MRFs versus payer MRFs.
touch_appTap or click any element name to reveal its definition and why it matters.
On smaller screens, scroll the comparison sideways to view all periods.
| Data Element | Original RuleEff. Jul 2022 | Schema 1.xUpdates 2023 to 2024 | Schema 2.0Eff. Feb 2026 | 2026 Final RuleFuture applicability |
|---|---|---|---|---|
| REPORTING ENTITY | ||||
Reporting Entity NameThe 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 TypeWhether 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 NameThe 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 IDA 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 TypeWhether 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 OnThe 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 |
VersionThe 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 ArrangementThe 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 NameA 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 CodeThe 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 TypeThe 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 VersionThe 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 |
DescriptionA 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 CodesWhen 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 ServicesFor 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 TypeThe rate type, such as negotiated, derived, fee schedule, percentage, or per diem. Why it matters: The type determines interpretation. A percentage is not a dollar amount, and its reference basis must be verified rather than assumed to be Medicare. | Introduced | check | check | check |
Negotiated RateThe published negotiated amount or percentage for the specified provider and service. Why it matters: A published rate is not proof of actual payment, patient responsibility, or realized collections. | Introduced | check | check | check |
Expiration DateThe 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 ClassWhether 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. | N/A | N/A | Introduced | check |
Service CodePlace-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 ModifierTwo-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 InformationFree-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 IDA 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. | N/A | 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 NumberThe 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 NameThe 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. | N/A | N/A | Introduced | check |
Network NameThe 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. | N/A | N/A | Introduced | check |
| OUT-OF-NETWORK DATA | ||||
Billed ChargeThe 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 AmountThe 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 NPIsIdentifies out-of-network providers subject to the applicable claims-reporting threshold. The original threshold is 20 claims; the 2026 final rule lowers it to 11 when the amendment applies. Why it matters: The reporting threshold limits disclosure from small samples. See future applicability dates above. | 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 CodeThe 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 ClassWhether 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. | N/A | N/A | Introduced | check |
| CONSUMER PRICE TOOL (RELATED REQUIREMENTS) | ||||
500 Shoppable ItemsPlans 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. | N/A | Introduced | check | check |
All Covered Items and ServicesFor plan or policy years beginning on or after January 1, 2024, the price comparison disclosure expands beyond the initial 500 items and services to all covered items and services. Why it matters: This is a consumer disclosure obligation, not a field introduced by the 2026 MRF schema. | N/A | Introduced | check | check |
Phone Cost-Sharing DisclosureFinalized amendments require the same cost-sharing information by phone upon request. Applies for plan or policy years beginning on or after January 1, 2027. Why it matters: Extends access and aligns the disclosure with No Surprises Act requirements. | N/A | N/A | N/A | Finalized: future |
| FINALIZED CHANGES WITH FUTURE APPLICABILITY | ||||
MRF Location FileA root-level text file identifying MRF locations and a monitored contact email. Contextual-file provisions apply September 6, 2027; initial posting follows the calendar-quarter timing rule. Why it matters: Supports predictable file discovery and technical inquiries. | N/A | N/A | N/A | Finalized: future |
Utilization FileIdentifies providers reimbursed for at least one covered claim in the specified reference period. Annual posting begins July 1, 2028. Why it matters: Provides context for provider participation. It is not a complete claims dataset or a service-volume forecast. | N/A | N/A | N/A | Finalized: future |
Taxonomy FilePublishes the internal taxonomy mapping or rules used to exclude unlikely provider-service combinations. Why it matters: Helps explain why provider-rate combinations were excluded from the in-network file. | N/A | N/A | N/A | Finalized: future |
Network-Level ReportingIn-network files are organized by provider network rather than by each plan or policy when the amendments apply. Why it matters: Reduces repeated rates across plans that share a network. | N/A | N/A | N/A | Finalized: future |
Quarterly Reporting CadenceIn-network and out-of-network files move from monthly to quarterly posting, beginning with the first calendar quarter after March 6, 2027. Why it matters: The first quarterly posting date is April 1, 2027. Finalization alone does not change the current cadence. | N/A | N/A | N/A | Finalized: future |
Footer Link RequirementA homepage footer link titled Price Transparency or Transparency in Coverage directs users to the MRF page. Applies September 6, 2027. Why it matters: Creates a predictable navigation path to published files. | N/A | N/A | N/A | Finalized: future |
Attestation and Senior OfficialAdds attestations and senior-official identification as specified for the applicable file types. Why it matters: Establishes accountability for complete and accurate disclosures. | N/A | N/A | N/A | Finalized: future |
Out-of-Network Reporting ChangesLowers the reporting threshold from 20 to 11 claims, extends the reporting period, and aggregates allowed amounts by insurance market type when applicable. Why it matters: Expands reported information while maintaining a privacy threshold. | N/A | N/A | N/A | Finalized: future |
IntroducedElement first required in this rule
Finalized: futureSee applicability and posting dates above
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 October 2026 final rule supersedes the proposal; its changes have the separate future dates described above. The consumer price-tool rows describe related disclosure obligations, not MRF data fields. For authoritative requirements and updates, seeCMS Schema 2.0 guidance and theCMS final-rule fact sheet.