Interoperability, Transparency in Coverage and Machine Readable Data

 

What's on this page:

Cost transparency

As part of the Transparency in Coverage Final Rule set forth by the U.S. Department of the Treasury, the U.S. Department of Labor, and the U.S. Department of Health and Human Services, health insurance issuers are required to make available to the public negotiated rates for all covered items with in-network providers, and historical payments to and billed charges from, out-of-network providers through machine-readable files (MRFs) posted on an internet website, updated monthly. These files will permit the public to have access to health plan payment information that can be used to understand health plan pricing and the cost for health care services.

The files that are posted will include:

  • Table of Content files(s)
  • In-network provider negotiated rate files
  • Out-of-network provider historic allowed amount files

To support the Transparency in Coverage final rules, WellSense has published machine-readable files (MRFs) for our Qualified Health Plans in JSON format.

  • Below is a link to our Table of Contents file. This file references the locations from which each appropriate machine readable file can be downloaded.
  • These files will be updated on a monthly basis.
  • Please note these may be very large data files. To download these files, an application designed to handle large data files may be needed.
  • Pricing information may be subject to change between when the file was published and the next monthly update.

These machine-readable files are formatted to allow researchers, regulators, consumer advocates, and application developers to more easily access and analyze data. These files may not be useful for members. Members are encouraged to access their health plan coverage materials instead to learn more about their benefits. For questions, please contact: ITOpsSupport@wellsense.org.

 

Coverage criteria transparency

In accordance with the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), we provide public reporting on our prior authorization processes to promote transparency.

Prior authorization is used to ensure certain services and treatments meet coverage and clinical guidelines before care is delivered. As part of this regulation, we share key metrics such as approval rates and decision timeframes to give members and providers greater visibility into how decisions are made.

These reports reflect data for CY2025, with updated reporting to be published annually in subsequent years.

Reports

Items and services lists

 
Some medications and services require prior approval (also called prior authorization) from WellSense before they will be covered. The tool below allows members, providers, and the general public access to see the list of criteria that must be met in order for certain medications and services to be covered by WellSense. Members and providers will need to register once during each calendar year.

Plan, provider and formulary data

CMS requires health insurance issuers to publish provider and formulary data in a machine-readable format, which provides a structured and predictable dataset that supports the function of HealthCare.gov’s Decision Support Tools, and is used by third-party application developers and researchers. 

The index file below includes the following types of information:

  • Plans files, which contain information on WellSense plans
  • Provider files, which contain information identifying each participating provider in the WellSense network
  • Drugs or formulary files, which contain information about the drugs covered by WellSense

Please note these may be very large data files. To download these files, an application designed to handle large data files may be needed. These files may not be useful for members. Members are encouraged to access their health plan coverage materials instead to learn more about their benefits.