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Machine Readable Files

To comply with the Federal Transparency in Coverage requirements we are sharing Machine Readable Files. These files provide information on the following:

These files contain the prices providers charge for care. We use these amounts and apply negotiated rates for in network providers or the allowed amount for out of network providers and then apply your benefits to see how to pay the claim, including what we owe and what you owe, if anything.

Price transparency requirements can result in very large file sizes which may, in turn, cause issues while downloading them. These Machine Readable files meet CMS requirements and by definition are meant to be used by machines (computer systems) for further processing. We follow CMS guidelines regarding formatting, and it may be helpful to reference the CMS Transparency Guide.

Due to the size of these files, these formats are not compatible with Excel or PDF file reading applications. The files require JavaScript Object Notation (JSON) support tools or third-party assistance. If your system has limited capability, they may not be downloadable. Download speeds and time are dependent on your internet speed, browser and computer hardware. To download these files, an application designed to handle large data files may be recommended. Depending on your operating system, you may need to download a tool to open.

Moda Health will update these Machine Readable files monthly.

To determine if you are a Non-ASO Group or an ASO Group, please call our customer service team at 888-217-2363

Journey to transparency

Sharing these files is the first step in our commitment to deliver cost transparency for our members. In 2023, we will incorporate this information into our Healthcare Cost Estimator tool, making it easier to find the information catered to your benefits and providers. Thank you for your patience as we take this journey to price transparency.

Here's the legal language that talks through Machine Readable Files.

The Departments of the Treasury, Labor, and Health and Human Services issued the Transparency in Coverage final rules on November 12, 2020. The rules require health insurance issuers in the individual and group markets (plans and issuers) to disclose certain pricing information. Under the final rules a plan or issuer must disclose in-network negotiated rates and out-of-network billed and allowed rates through two machine-readable files posted on an internet website.

Understanding the Data

Machine-readable files published by Moda Health conform to the technical implementation guide and schema version 1.0.0 published by CMS at https://github.com/CMSgov/price-transparency-guide

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