Claims Data

CMS has made it clear in their FAQs that providers should populate payer-negotiated rates in the MRFs based on actual contracted amounts and fee schedule amounts, rather than using historical claims reimbursement information. This distinction is crucial for compliance. Payer-specific negotiated rates included in MRFs should not be derived from claims data.

Separate from negotiated rates though, claims data does serve three significant purposes related to price transparency requirements:

1. Capturing all Services Provided

Outpatient soft-coded CPTs are procedures coded after services are rendered and are typically found in clinical data within a patient accounting system. These codes appear on final claims after bill edits associated with specific revenue codes such as 360 (operating room services) or 481 (cardiology services).

To incorporate soft-coded CPTs into MRFs, Turquoise reviews a six-month period of billed claims to identify soft-coded procedures. These procedures, often high-cost surgeries, are typically not found in the CDM but do have negotiated rates in commercial payer contracts and fee schedules. We add these identified services to the MRF to ensure comprehensive service capture. You can read more about our soft-coded CPT processes here.

2. Percentile Allowed Amounts (1/1/2026-)

Beginning 1/1/2026, CMS replaced the Estimated Allowed Amount requirement with Percentile Allowed Amounts for negotiated rates that cannot be expressed as a single, fixed dollar amount in advance (i.e., algorithmic or percentage-based rates).

Hospitals must use historical paid claims/remittance data to show a distribution of what they actually received for a given payer and service. Specifically, hospitals must include in the MRF:

• 10th percentile allowed amount (dollar amount)
• Median allowed amount (dollar amount)
• 90th percentile allowed amount (dollar amount)
• Count of allowed amounts used to calculate those figures

These percentile values must be calculated using a historical lookback period of 12–15 months and should be based on remittance-derived allowed amounts (or an equivalent remittance data source). This change is intended to make estimated amounts more transparent by showing a payment range rather than a single average.

The Turquoise process for reporting the Percentile Allowed Amounts involves calculating the 10th, 50th, and 90th percentile reimbursement amounts (by service and payer) directly from 835 remittance files.

3. Publishing Shoppable Service Packages or a Patient Estimator Tool

Claims data helps in creating shoppable service packages to fulfill the shoppable services requirement of the final rule. A patient estimate tool allows patients to estimate their out-of-pocket costs for various services based on historical claims data.

By leveraging claims data for these purposes, Turquoise Health ensures that the MRFs are accurate, comprehensive, and compliant with CMS regulations, ultimately enhancing transparency and usability for both hospitals and patients.