How to display Tiered Networks

[MJLevineHMK]

Where we have plans/products that have tiered-networks, i.e., tier 1=primary network that pays at the highest level, tier 2=secondary network/in-network Providers, but pays at a lower level, are we required to report the Provider Prices for each of the networks or at the primary network only?

[Ginger228]

Per the rule we are required to report all negotiated rates for in-network provider. If the contract has different rates for the same procedure code both rates should be displayed on the MRF. If needed the additional_field could be used to show one rate is for a Tier 1 network.

[shaselton-usds]

@MJLevineHMK @Ginger228 Is there a way that you'd want this demonstrated in the schema that would be more formalized?

[Ginger228]

@shaselton-usds
Apologies for the delayed response.
If the tiering is based on benefits meaning the out of pocket expense for the member, I believe a new filed is needed in the Provider Object to indicate if the TIN/NPI is a Tier provider for the plan.

<provider_groups>



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ein

yes