Machine-readable files published by Blue Cross NC conform to the technical implementation guide and schema version 1.0.0 published by CMS in their price transparency guide.
The machine-readable files do:
- Include information on the rate insurers have negotiated with in-network providers for all covered items and services.
- Have a significant amount of data (estimated at 1 Terabyte per file), making it difficult to download using an average system or wireless connection.
The machine-readable files do NOT:
- Include meaningful information, such as an estimate of the cost members will be responsible for paying for an item or service. Individual costs vary depending upon the terms of the individual’s specific health insurance coverage or reimbursement arrangement.
- Guarantee payment and may not always reflect amounts on final claim processing documentation. Eligibility and benefit determinations are made when the claim is processed by Blue Cross NC.
Additional Disclosures:
- 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.
- 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 code 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.
Blue Cross NC has an online tool designed specifically for consumers that includes cost estimates for the entire episode of care. Beyond what is available publicly, Blue Cross NC customers can use the tool to access specific, transparent pricing information based on their individual plans. This allows customers to see what they will pay for a procedure and compare prices by location and provider, so they can make informed health care decisions.
Price transparency can add significant value, but more action is needed to make quality, equitable health care more affordable. That is why we stay focused on developing and building on existing tools, like our cost estimator tool, to improve access to quality care, lower costs and provide members with meaningful information so they can make the best choices for their health care.
For member-specific benefit information, view our Transparency of Coverage information.
