At its onset, hospital price transparency seemed like a straightforward concept — providing patients with clear and accessible information about the costs of medical services to enable consumers to make informed decisions about their health care. Consequently, its implementation has become a complex journey with the myriad of complicated new requirements mandated by CMS over the past few years, primarily associated with the Machine-Readable File (MRF) content and format. The latest requirements, effective January 1, 2026 with delayed enforcement to April 1, 2026, have created a new data challenge for hospitals to meet, compiling 835 payment data to extract and calculate key required reporting elements associated with specific payment structures (e.g., variable payment options, percent of charge payments for dynamic charges). The following outlines the key reporting changes:
Replacement of “Estimated Allowed Amount” in Certain Scenarios
When a particular service or procedure does not have a calculable or fixed payment rate (per diem, case rate, fee schedule, unit payment, etc.), CMS is now requiring reporting of compiled, stratified allowed amount data for the payor population as represented with these 4 new required elements: median allowed amount, 10th percentile amount, 90th percentile amount, and a count of the number of allowed amounts or claims used in these calculations. These 4 new data elements need to be populated and replace the “Estimated Allowed Amount” which is removed from the MRF format. Collectively, CMS is referring to this new reporting element as “Allowed Amounts Data Elements and the Count of Allowed Amounts Data Element”. Further, the data population must be extracted from a narrow time range of no less than 12 months and no more than 15 months past claims data.
The payment scenarios that are most impacted by these new rules include:
The most defensible, viable source of these detailed data elements is the 835 payment data (as also suggested and cited by CMS). Extracting, manipulating, and processing this information can be a daunting task for hospitals to handle internally.
Other New 2026 Requirements
CMS has also made other minor changes to the MRF header format and affirmation statement. Hospitals must now encode their National Provider Identifier (NPI) in the MRF header. Additionally, the hospital designee attesting to the affirmation statement must have their name encoded in the header.
With CMS compliance enforcement underway as of April 1, is your hospital’s price transparency file updated and compliant with these new requirements to avoid CMS imposed penalties? If not, MedCom is a trusted, valuable partner to forge the way.
MedCom Can Help with Price Transparency
MedCom can be a trusted partner in providing your facility with proficient payor contract and 835 data analytics to help you pinpoint the payors and services for which an expanded price transparency analysis needs to be completed to comply with CMS, pass their MRF compliance test, and avoid costly administrative and monetary penalties.
Contact us today at 412-481-7710 or admin@medcomsolutions.com to learn more about how we can assist with your needs for pricing transparency or any other revenue cycle service needs you may have. MedCom’s core line of business is proven to reduce denials, enhance revenues, and sustain results. MedCom specializes in Strategic Pricing, OR Charge Optimization, 835 Payment & Denial Trending Analytics in addition to a variety of CDM Management and Charge Capture Services including our proprietary, intuitive, and affordable charge master management Software-as-a-Service (SaaS), CMNavigator®. You Care for Patients. We Capture Charges.