We are working to help make healthcare costs more transparent. If you are a Moda Health member and want to find out the cost of care, visit the Healthcare Cost Estimator in your Member Dashboard. The Estimator has more than 200 medical codes that will help you understand how much insurance covers, how much you will pay and how much different providers charge. In 2023, this tool will add even more codes so it will be easier to find more information on more procedures.
Machine Readable Files are a tool for healthcare industry experts. These files share our negotiated rates, allowed amounts and billed charges. To view these files, you will need software tools that allow you to read very large files in the CMS JSON format. 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 Machine Readable files monthly.
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.
Plans and issuers are required to make these files public for plan policy years beginning with 2022. This material is for information only. Our health transparency information is general in nature and is not a substitute for diagnosis or treatment by a physician or other healthcare professional. Pricing included in the fee schedule data is accurate as of the date it is pulled from system files and may be subject to change between the date the pricing data is pulled and the next update of the files. This file, and the included pricing data, is not a guarantee of payment and may not always reflect amounts on final claim processing documentation. Eligibility and benefit determinations are made when the claim is processed.
Rates for codes appearing in the file may vary when a given code rate has a modifier applied or when member benefit or treatment characteristics result in certain rate adjustments. Different codes rates for the same codes may indicate that a modifier or some other type of member benefit or treatment characteristic applies. Billing codes that are not included in fee schedule data for in-network rates are not included in the file.
Price transparency requirements can result in very large file sizes which may, in turn, cause issues while downloading them. If you are experiencing problems, please try a different web browser or check your Internet/Wi-Fi speed.
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
Medical Customer Service is at 844-931-1779.
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