CMS to begin enforcing new price transparency requirements on April 1
CMS recently updated an MLN Fact Sheet on hospital price transparency requirements to reflect changes in the calendar year (CY) 2026 Outpatient Prospective Payment System (OPPS) final rule, which took effect on January 1. The agency will begin enforcing these new and updated requirements on April 1.
CMS removed the estimated allowed amount data element and replaced it with the following elements:
- Median allowed amount
- 10th percentile allowed amount
- 90th percentile allowed amount
- Count of allowed amounts
When a payer-specific negotiated charge is based on a percentage or algorithm, hospitals must encode the median, 10th percentile, and 90th percentile allowed amounts in dollars in their machine-readable files (MRF), according to the fact sheet. They must also encode the count of allowed amounts that it used to calculate the aforementioned data elements.
To calculate and encode these data elements, hospitals must use electronic data interchange 835 electronic remittance advice or an equivalent source of remittance data. For these elements, they must also reference a lookback period of no less than 12 to 15 months before posting their MRF.
In the CY 2026 OPPS final rule, CMS replaced the MRF Affirmation Statement with a new attestation statement data element. Additionally, hospitals are now required to encode the name of the hospital CEO, president, or senior official assigned to oversee the encoding of true, accurate, and complete data in their MRF. In a newly created general MRF data element, hospitals must now report any Type 2 national provider identifiers associated with a primary taxonomy code starting with “27” or “28” and active as of the date of the most recent update to the standard charge information.
CMS also noted that, as of January 1, it may reduce the amount of a civil monetary penalty when a hospital waives its right to an Administrative Law Judge hearing, under certain conditions.
Revenue integrity professionals should review their organization’s MRF to ensure it is in compliance with CMS’ current price transparency requirements.
Editor’s note: Find more NAHRI coverage on price transparency here.