Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Rating; Hospital Price Transparency; and Notice of Closure of a Teaching Hospital and Opportunity To Apply for Available Slots

1. Background a. CY 2024 OPPS/ASC Final Rule With Comment Period

This section of the background recites relevant history from the CY 2024 OPPS/ASC final rule with comment period, and all references in this section pertain to it.

In the CY 2024 OPPS/ASC final rule with comment period (88 FR 82083, 82097, 82184), we indicated we understand that hospitals establish payer-specific negotiated charges in many ways, ranging from basic fee schedules (in which dollar amounts for specific items and services are known) to grouper methodologies (in which a base rate in dollars has been established but may then be modified depending on other factors like transfers or outliers), to “percent of billed charges” schemes (in which the dollar amount varies from person to person and is not known until the services are performed). We demonstrated in Figure A in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82098) the components of an MS-DRG algorithm. An example of how Figure A may translate into an algorithm encoded in the MRF may be: base rate multiplied by the MS-DRG weight; outlier payment of $4,303 per diem when length of stay is greater than 2 times the average length of stay. Based on our experiences reviewing MRFs since finalizing the CY 2024 OPPS/ASC final rule with comment period, we have observed factors included in algorithms such as, but not limited to: weights based on resources required, mix of services provided within an episode of care, and thresholds or caps on the overall price of services billed within an episode of care. Therefore, we reiterate our stance outlined in the CY 2024 OPPS/ASC final rule with comment period that not all hospitals can produce a payer-specific negotiated charge in dollars that meets the definition of a “standard charge.”

As indicated in the CY 2024 OPPS/ASC final rule with comment period, we finalized a requirement for hospitals to display an estimated allowed amount which would provide needed context, in dollars, for instances where the hospital's payer-specific negotiated charge is based on a percentage or algorithm. We defined a new data element, the “estimated allowed amount,” at Sec. 180.20, as the average dollar amount that the hospital has historically received from a third party payer for an item or service.

We noted that we heard from interested parties that, when a hospital has negotiated a payer-specific negotiated charge that is based on an algorithm, an estimate displayed in dollars within the MRF is useful, particularly for making comparisons across hospitals (88 FR 82099). We stated, for example, that an estimate displayed in dollars would permit users to make price comparisons across hospitals when, regarding the same procedure and payer/plan, one hospital has established a payer-specific negotiated charge as an algorithm and a second has established a payer-specific negotiated charge as a dollar amount. After considering what additional data could be required in the MRF to provide further needed context for a payer-specific negotiated charge that is expressed as an algorithm or a percentage, we finalized the estimated allowed amount as a new data element at Sec. 180.20. We also required at Sec. 180.50(b)(2)(ii)(C) that hospitals calculate and encode an estimated allowed amount, in dollars, when hospitals have established a payer-specific negotiated charge that is based on a percentage or an algorithm. We stated that the estimated allowed amount is the average reimbursement in dollars that the hospital has received from the payer in the past. We further stated that the estimated allowed amount is therefore not prospective and is also not based on the hospital's chargemaster, which, as we understand it, contains only gross charges for itemized items and services, or claims submitted to the payer. As we explained (88 FR 82099 through 82100), because the estimated allowed amount data element is meant to provide an estimate of what the algorithm produces in dollars, across the universe covered by a particular payer's plan, such an amount should reflect the amount the hospital expects to be reimbursed for the item or service (or service package), on average. We stated that we believed this information provides context to the public that is necessary to compare payer-specific negotiated charges across hospitals and is a valuable benchmark that innovators can use to develop price estimator tools to estimate an individual's personalized out-of-pocket costs. We stated that we believed this information, when paired with the algorithm encoded in the MRF, would promote greater transparency of hospital standard charges that can be useful to MRF users. b. Background Subsequent to the CY 2024 OPPS/ASC Final Rule With Comment Period

Since the CY2024 OPPS/ASC final rule with comment period was finalized, we have continued to gain experience with the implementation of the estimated allowed amount data element and received public feedback and questions requesting that we further clarify its calculation. Based on our observations through comprehensive audits and feedback from users of the data, and consistent with Executive Order 14221, we proposed to revise the HPT regulations to recast the estimated allowed amount data element to better require, through new data elements, disclosure of dollar amounts for items and services in hospital MRFs, which we believe would enhance transparency and comparability of payer-specific negotiated charges across hospitals. Specifically, and as further discussed later in this section, we proposed to require hospitals to report four new data elements when a payer-specific

negotiated charge is based on a percentage or algorithm--the median allowed amount (which would replace the estimated allowed amount data element), the 10th percentile and 90th percentile allowed amounts, and the count of allowed amounts used to calculate the median, 10th, and 90th percentile allowed amounts. 2. General Comments

Comment: Many commenters, including, for example, hospitals and hospital associations, information technology developers, researchers, employers, payers, healthcare consumers, and consumer advocates expressed support for the Administration's goals of making more meaningful price information available to patients to support a more competitive, innovative, affordable, and higher quality healthcare system. Many commenters also supported our continued commitment to improving price transparency and the clarity of healthcare pricing. Many commenters agreed that price transparency supports consumers' ability to plan and make informed decisions about their care and to select high value providers. Several commenters indicated how complete, accurate, and timely price transparency can be a powerful tool allowing employers, innovators, researchers, policy makers, and public and private payers to have a truer picture of where cost pressures may lie and how they may be mitigated.

Response: We appreciate the overwhelming support for CMS price transparency policies, which include HPT, TiC, and the implementation of the No Surprises Act (NSA). We agree with commenters who believe that price transparency can stimulate provider competition, empower healthcare consumers, and result in lower healthcare costs. We agree that transparency in healthcare pricing is integral to supporting a transition to value-based care. We further agree that transparency in healthcare pricing is a societal benefit that can facilitate competition and comparison shopping to lower healthcare costs, and that policies that promote providing accurate and complete data ensure users of the MRF (such as employers and researchers) have the information they need to draw comparisons for contracting or research purposes, or support innovators as they develop products to enable patients' well- informed healthcare decisions.

Comment: Several commenters were generally supportive of the proposed regulatory requirements. Several commenters agreed that while some proposals may be useful, CMS should focus on policies that directly help patients understand the costs of their care rather than increasing administrative requirements on hospitals. A few commenters appreciated the agency revisiting the HPT policies to ensure that the information hospitals disclose in their MRFs is accurate and complete, so the information is maximally actionable for healthcare purchasers and consumers. A few commenters supported our efforts to simplify and streamline requirements, including MRF standardization, as such standardization facilitates actionable comparisons, and reduces the administrative burden of complying with these rules. One commenter indicated that ensuring that MRFs are available, timely, and accurate is the foundation upon which innovators can build tools that actually help patients navigate the cost of healthcare, but the commenter expressed that the data in the MRFs are insufficient on their own to fully support a patient's understanding of their individual price, and offered the view that final rules governing MRF creation must work in tandem with the NSA policy.

Response: We thank commenters for their support of the proposals. As we stated in the CY 2020 HPT final rule (84 FR 65571), we believe there is a direct connection between hospital standard charge information transparency and more affordable healthcare and lower healthcare costs. We believe healthcare markets can work more efficiently and provide consumers with higher value healthcare if we promote policies that encourage choice and competition. As we have stated on numerous occasions (for example, 84 FR 65526), we believe that transparency in healthcare pricing is critical to enabling patients to become active consumers so they can lead the drive towards value. As we stated in the CY 2020 HPT final rule (84 FR 65571), we continue to encourage hospitals to provide consumers with cost information in a consumer-friendly manner. We agree with commenters that standardization facilitates more actionable comparisons of the MRF data, and that over time standardization will reduce burden to hospitals and payers. We continue to affirm the premise we articulated in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82080), that HPT regulations requiring hospitals to make public standard charges are a necessary and important first step for driving competition and in ensuring transparency in healthcare prices for the public. But, while foundational, we believe the release of hospital standard charge information alone is insufficient to achieve our ultimate goals for price transparency to help drive marketplace competition and consumer shopping. Instead, healthcare consumers' more complete understanding of real prices would come in tandem with other price transparency policies, including TiC and NSA.

Comment: Many commenters who opposed the proposals highlighted the operational and data complexities for hospitals--particularly for small, rural, and/or safety-net hospitals--in implementing the proposed changes. Several commenters provided examples of the operational burden, noting recent revenue losses, constrained resources, necessity of hiring vendor support to meet the requirements, and concern about the amount of time required for implementation. Several commenters noted that the steady stream of new HPT requirements has forced hospitals into a far more frequent update cycle, and asked that we stop adding new requirements. Several commenters recommended that CMS maintain the HPT rules in their current form and seek ways to reduce hospital burden. A few commenters cited Executive Order 14192 (Unleashing Prosperity Through Deregulation, issued January 31, 2025) and stated that we should be actively seeking ways to reduce hospital burden. A few of these commenters urged us to ensure HPT requirements are implemented with flexibility, clear technical guidance, and a supportive compliance framework that acknowledges the complexity of hospital pricing arrangements.

Response: We believe the benefits of these proposals to the public outweigh the burden on hospitals. The American public overwhelmingly supports healthcare price transparency. A September 2024 poll found that 92 percent of Americans want requirements for hospitals to provide upfront prices.\444\ Additionally, these proposals align with the President's Executive Order 14221 directing that we require the disclosure of actual prices and ensure that pricing information is easily comparable across hospitals. We believe that continued use of a standardized format to encode and display this information will improve the public's understanding of the standard charges hospitals have established as well as reduce hospitals' burden over time. We will provide

technical guidance and examples of how to encode the new data elements we are finalizing in this rule on the CMS Hospital Price Transparency-- Data Dictionary GitHub Repository, as well as in guidance on the HPT resources page on the CMS website. After consideration of comments, we are finalizing increased burden estimates found in section XXIII., Collection of Information Requirements”, of this final rule with comment period. Further, we are delaying enforcement (discussed in more detail in section XIX.B.7. of this final rule with comment period) of the revisions to Sec. 180.50 to April 1, 2026, to provide hospitals with more time to comply.

\444\ PatientRightsAdvocate.org. (2024). Transparency Survey 2024. https://www.patientrightsadvocate.org/patient-rights-advocate-bipartisan-pollster-memo-2024.

Comment: Many commenters stated that we should prioritize efforts to improve the price comparison tools that are accessible to consumers who want to know their out-of-pocket costs, instead of layering more hospital regulatory requirements with respect to tools like MRFs that are not consumer-friendly. A few commenters asked CMS not to finalize these proposals, stating that the burden to implement them would outweigh the utility of the information for patients, and that the vast amounts of data presented in the MRF format, including hospital “standard charges,” are not consumer-friendly and do not provide patients with the personalized, prospective information they need to make informed decisions.

Response: We appreciate commenters' suggestions that we should focus on improving policies that directly help patients understand costs, and we may revisit the consumer-friendly display requirements in future rulemaking. While we understand the comment that MRFs may not be primarily intended for direct patient use, we disagree that they have little utility for patients and the public. The MRF format is designed to be parsed and analyzed by entities including innovators, employers, researchers, and journalists who transform that structured data into products, tools, research, and reports to support patients' ability to understand and compare hospital prices, which ultimately drives competition and directly benefits patients.

Since the HPT requirements went into effect on January 1, 2021, we have seen numerous examples of researchers and industry experts using MRFs to uncover potential savings by analyzing variation in payer- specific negotiated charges and discounted cash prices for the same items and services within and across hospitals; employers using the data to negotiate more competitive rates; and innovators identifying and aggregating the hospital price data for consumers to make more meaningful comparisons.445 446 447 448 The impacts are beginning to be reflected in hospital pricing data. For example, a research report by Turquoise Health found that negotiated rates began converging between December 2021 and June 2024, and researchers from the University of Miami found that in Florida, “patients seeking elective, self-paid care responded [to hospital price transparency] by choosing hospitals that were transparent about their prices, and hospitals, in turn, responded by simplifying their pricing and reducing the intensity of services.” 449 450

\445\ Mouslim. https://doi.org/10.1377/forefront.20211103.716124.

\446\ Smith, C., Singleton, A., Lewis, D., & Allen, B. (2022, May 3). Hospital price transparency data: Case studies for how to use it. Milliman. https://us.milliman.com/en/insight/hospital-price-transparency-data-case-studies-for-how-to-use-it.

\447\ Minemyer, P. (2022, September 8). New playbook aims to help employers, plan sponsors negotiate hospital prices. Fierce Healthcare: Payer. https://www.fiercehealthcare.com/payers/new-playbook-aims-help-employers-plan-sponsors-negotiate-hospital-prices.

\448\ https://turquoise.health/patients.

\449\ Xiao, F. (2024, October 23). Examining the healthcare market response to transparency regulations: Healthcare prices have begun to converge. Here's a detailed look into our analysis. Turquoise Health. https://blog.turquoise.health/examining-rate-trends-by-annualized-rate-change-over-time/.

\450\ Yaraghi, N., & Pan, X. (2025, September 9). The hospital price transparency rule is working, but patients still need help using it. Brookings Institute. https://www.brookings.edu/articles/the-hospital-price-transparency-rule-is-working-but-patients-still-need-help-using-it.

Comment: Many commenters pointed out the need for more policy coordination across the various price transparency initiatives (HPT, TiC, NSA and state level efforts), and the importance of not addressing HPT policies in isolation. These commenters stated that price transparency efforts would benefit from a comprehensive review of the numerous and sometimes conflicting requirements at both the State and Federal levels and urged us to focus future efforts to reform price transparency on streamlining policies to reduce the risk of conflicting information while improving accuracy, as well as alleviating costly administrative burden for both providers and insurers. Several commenters explained that with the recent Federal requirements for insurers and health plans to publicly share detailed pricing data, hospitals are no longer the most suitable or effective entities for this task. One commenter strongly felt that these proposals are shifting the responsibility of the plan's benefit design and education from the payers themselves to providers.

Response: We believe the HPT requirements we proposed to modify are complementary to other price transparency efforts such as the NSA. We note that in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82079), we sought comment on alignment between HPT policies related to the consumer-friendly display requirements at Sec. 180.60 which we may consider in future rulemaking. We acknowledge some states may have their own additional or more stringent requirements to promote price transparency. We also acknowledge that for patients with employer-based insurance, their health plans may have additional data to help the patient understand their out-of-pocket obligation, but, as stated above, the MRFs are a key foundational data source to support driving efficiency in health care. We continue to evaluate opportunities to improve coordination and further alignment across related Federal price transparency initiatives and policies.

Comment: Many commenters provided other suggestions on how to improve the HPT requirements and resources. In particular, commenters made recommendations on how to enhance the CMS template for the MRF. Several commenters recommended we add or remove data elements/ attributes to or from the CMS template, particularly related to the hospital license number, hospital points of contact, the de-identified minimum negotiated charge, the de-identified maximum negotiated charge, the standard charge methodology, payer/plan name, billing class, stop loss, outliers, carve-outs, general contract provisions, a count of services, and plain language item/service descriptions. A few commenters suggested we further align data element/attribute names in the HPT MRFs with those in the TiC MRFs. A few commenters recommended limiting the display of items and services in the MRF. A few commenters recommended that we require hospitals to combine standard charge information with quality, health outcomes data and/or clinical data. A few commenters recommended that we require hospitals to group standard charge information by episodes of care. One commenter suggested eliminating the JSON format of the CMS template.

Several commenters provided recommendations for potential updates to the technical specifications in the CMS Hospital Price Transparency- Data Dictionary GitHub repository or to the Hospital Price Transparency validator tool. A few commenters requested we

increase the number of errors displayed in the online validator tool. A few commenters recommended that we clarify in the Hospital Price Transparency-Data Dictionary GitHub repository technical specifications that hospitals are required to make public their discounted cash prices for items and services, if the hospital has established a discounted cash price for an item or service. Several commenters requested that we provide enhanced technical assistance, guidance, or support to specific kinds of hospitals or in specific scenarios and increase engagement with hospitals. A few commenters suggested we provide financial support to hospitals to help them implement any new requirements finalized. One commenter recommended we implement the HHS Office of Inspector General's (OIG) recommendation to create a training and compliance program tailored for small and rural hospitals. One commenter requested we establish a multi-stakeholder technical advisory group, made up of hospitals, physicians, information technology firms, accounting firms, insurers, and patients to develop future HPT requirements and guidance.

A few commenters suggested we make updates to the requirements for displaying shoppable services in a consumer-friendly manner at Sec. 180.60, with some of these commenters indicating we should eliminate these requirements as they feel they are no longer necessary as a result of the TiC and NSA regulations. Other commenters recommended that we: update, expand, or enhance the requirements for displaying shoppable services in a consumer-friendly manner; require hospitals to combine standard charge information with quality, health outcomes, and/ or clinical data; and require hospitals to group standard charge information by episodes of care.

A few commenters requested we modify or vary the scope of the HPT requirements. A few commenters suggested tailoring the HPT requirements based on hospitals' specialty/size/patient volume. One commenter requested we expand the HPT requirements to include the disclosure of professional fees for providers not directly employed by hospitals.

Other commenters offered other HPT-related suggestions, with one recommending we consider strategies states are using to improve and enforce state-level HPT requirements, and another requesting that we further engage with patients in developing future HPT requirements.

Several commenters provided suggestions related to improving the TiC and NSA regulations, the 340B program, transparency of Medicare and Medicare Advantage rates, and extending the HPT requirements to other providers.

Response: While these comments are out of scope for this final rule because they do not relate to the specific proposals, we thank commenters for their suggestions on how to improve the HPT requirements and resources and may consider these comments with respect to future rulemaking, guidance, resources, and/or HPT enforcement process improvement. 3. Definitions

At Sec. 180.20, we proposed to add definitions for three new data elements, the “median allowed amount,” the “tenth (10th) percentile allowed amount,” and the “ninetieth (90th) percentile allowed amount.” We stated in the proposed rule that these data elements would be defined as follows:

“Median allowed amount” is defined as the median of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no longer than the 12 months prior to posting the machine-readable file. Should the calculated median fall between two observed allowed amounts, the median allowed amount is the next highest observed value.

“Tenth (10th) percentile allowed amount” is defined as the 10th percentile of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no longer than the 12 months prior to posting the machine-readable file. Should the calculated percentile fall between two observed allowed amounts, the 10th percentile allowed amount is the next highest observed value.

“Ninetieth (90th) percentile allowed amount” is defined as the 90th percentile of total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no longer than the 12 months prior to posting the machine-readable file. Should the calculated percentile fall between two observed allowed amounts, the 90th percentile allowed amount is the next highest observed value.

We discuss these definitions in more detail in sections below.

Comment: A few commenters supported our proposals to add the definitions for these three data elements. The commenters noted that more precise definitions will ensure that hospitals are interpreting the specifications correctly and patients will have more accurate data to allow them to make more informed decisions.

Response: We thank commenters for their support.

Comment: We received many comments on the proposed 12-month lookback period referenced in these definitions, as well as on the proposed definitions of the allowed amounts and how to calculate them when the percentiles fall between two observed allowed amounts.

Response: We address these comments in later sections on the lookback period and allowed amounts. As discussed in those sections, in light of these comments, we are finalizing these proposals with modification. Specifically, we are finalizing our proposed definitions for three new data elements, the “median allowed amount,” the “tenth (10th) percentile allowed amount,” and the “ninetieth (90th) percentile allowed amount” with modification to revise the phrase, “no longer than the 12 months” to state, “no less than 12 months and no longer than 15 months.”

Final Action: After consideration of public comments, we are finalizing the proposed definitions of “median allowed amount,” “tenth (10th) percentile allowed amount,” and “ninetieth (90th) percentile allowed amount” with modification to reflect a lookback period of no less than 12 months and no longer than 15 months prior to posting the MRF. These data elements will be defined as follows:

“Median allowed amount” is defined as the median of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no less than 12 months and no longer than 15 months prior to posting the machine- readable file. Should the calculated median fall between two observed allowed amounts, the median allowed amount is the next highest observed value.

“Tenth (10th) percentile allowed amount” is defined as the 10th percentile of the total allowed amounts the hospital has historically received from a third-party payer for a time period no less than 12 months and no longer than 15 months prior to posting the machine-readable file. Should the calculated percentile fall between two observed allowed amounts, the 10th percentile allowed amount is the next highest observed value.

“Ninetieth (90th) percentile allowed amount” is defined as the 90th percentile of total allowed amounts the hospital has historically received from a third-party payer for a time period no

less than 12 months and no longer than 15 months prior to posting the machine-readable file. Should the calculated percentile fall between two observed allowed amounts, the 90th percentile allowed amount is the next highest observed value. 4. Replacing the Estimated Allowed Amount With the Allowed Amounts Data Elements and the Count of Allowed Amounts Data Element a. Background on Encoding Payer-Specific Negotiated Charges as Dollar Amounts

As noted in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82099), we have learned that most commercial contracting methods allow a hospital to identify and display as a dollar figure the payer- specific negotiated charges they have established with third party payers. Accordingly, we stated that we expect that, for most contracting scenarios, a hospital's payer-specific negotiated charges can also be expressed as a dollar amount.

As discussed in the CY 2026 OPPS/ASC proposed rule (90 FR 33476), hospitals and MRF users have indicated in inquiries to CMS that they are confused about our current requirements for encoding payer-specific negotiated charges, so we clarified our current policy in the proposed rule. We stated that if a dollar amount can be derived from a hospital's payer-specific negotiated charge, it must be encoded as a dollar value in the MRF. For items and services encoded in the MRF with a “standard charge methodology” of “case rate,” “per diem,” or a known “fee schedule,” we stated that we expect hospitals will be able to encode a “payer-specific negotiated charge: dollar amount.” We recognized that there may be situations where the payer-specific negotiated charge is a percentage of a fee schedule that is not available to the hospital. In such instances, under our existing policies, we stated the hospital must encode a “payer-specific negotiated charge: percentage” and an estimated allowed amount (which we stated would be replaced with the median allowed amount should our proposal be finalized) and may indicate in the additional notes data element the type of fee schedule. We noted that hospitals encoding a case rate or per diem as the standard charge methodology must encode the dollar amount for the service package base rate, which may be coupled with a “payer-specific negotiated charge: algorithm” and an estimated allowed amount (which we stated would be replaced with the median allowed amount should our proposal be finalized). We encouraged readers to review the scenarios and examples on the CMS Hospital Price Transparency--Data Dictionary GitHub Repository website for examples of how to encode standard charge information,\451\ and additional guidance on CMS' HPT website.\452\

\451\ CMS, (2024, June), Hospital-Price-Transparency Examples, Hospital Price Transparency, GitHub. https://github.com/CMSgov/hospital-price-transparency/tree/master/examples.

\452\ CMS, (2025, May), Resources, Hospital Price Transparency website at https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency/resources.

Comment: A few commenters commented on our clarification that if a dollar amount can be derived from a hospital's payer-specific negotiated charge, it must be encoded as a dollar value in the MRF. One commenter indicated they appreciated the May 22, 2025 guidance we provided at the CMS Hospital Price Transparency website's “Resources” page on this topic, titled “Updated Hospital Price Transparency Guidance Implementing the President's Executive Order (E.O.) `Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information,' ” (“May 22, 2025 guidance”) indicating they believe it is an important step towards ensuring the accuracy and completeness of the MRF data. Another commenter indicated they had not encountered any scenarios where a known fee schedule, case rate, or per diem exists outside of a more complicated and detailed algorithm and provided examples of factors that may further modify a fee schedule, case rate, or per diem, including carveouts, “lesser of” methodology, stop loss provisions, exclusions, and grouper logic. Therefore, this commenter recommended CMS reconsider the emphasis on the “payer-specific negotiated charge: dollar amount” data element in the MRF. A few commenters indicated they do not currently encode the “estimated allowed amount” if they can calculate the “payer-specific negotiated charge: dollar amount” of a known fee schedule, case rate, or per diem.

Response: We thank the commenters for their support of our guidance that if a dollar amount can be derived from a hospital's payer-specific negotiated charge, it must be encoded as a dollar value in the MRF. We continue to believe that for many items and services encoded in hospitals' MRFs with a “standard charge methodology” of “case rate,” “per diem,” or a known “fee schedule,” hospitals will be able to encode a “payer-specific negotiated charge: dollar amount,” as evidenced by a few commenters that indicated they are currently doing so. We recognize that there may be situations where the payer- specific negotiated charge for a particular item or service is further modified by a percentage or an algorithm, as suggested by one commenter. We clarify that if there are percentages or algorithms that modify the negotiated rate for an individual item or service, hospitals must encode the base rate for that item or service in the “payer- specific negotiated charge: dollar amount,” which must be coupled with a payer-specific negotiated charge percentage or algorithm, and hospitals must also encode the allowed amounts and count of allowed amounts we are finalizing in this rule (discussed in more detail below). For payer contract provisions that are negotiated at an aggregate level across multiple items and services (for example, claim level or episode of care), in the CMS Hospital Price Transparency--Data Dictionary GitHub Repository we provide guidance on the use of an optional data element, “general contract provisions,” that hospitals may, but are not required to use to convey this information. We point readers to the Hospital Price Transparency--Data Dictionary GitHub Repository available at https://github.com/CMSgov/hospital-price-transparency for additional details about this optional data element. b. Replacing the Estimated Allowed Amount With the Median Allowed Amount and Adding the 10th and the 90th Percentile Allowed Amounts

In the CY 2026 OPPS/ASC proposed rule (90 FR 33476), we proposed to revise Sec. 180.50(b)(2)(ii)(C) to require, at new Sec. 180.50(b)(2)(ii)(C)(2), that, beginning January 1, 2026, if a payer- specific negotiated charge is based on a percentage or algorithm, the hospital must calculate and encode the median allowed amount in dollars for that item or service. As noted above, we proposed to define “median allowed amount” in Sec. 180.20 as the median of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no longer than the 12 months prior to posting the MRF. We stated in the proposed rule that should the calculated median fall between two observed allowed amounts (in other words, where the total count, n, is an even number), we proposed that the median allowed amount would be the next highest observed value. As we stated in the proposed rule, we believe requiring hospitals to encode the

median allowed amount in the circumstances described in Sec. 180.50(b)(2)(ii)(C), rather than the estimated allowed amount, defined as the average dollar amount that the hospital has historically received from a third party payer for an item or service, would improve the public's ability to better understand, and, therefore, more meaningfully use, payer-specific negotiated charges, and would make such charges more comparable across hospitals.

We also proposed to revise Sec. 180.50(b)(2)(ii)(C) to require at new Sec. 180.50(b)(2)(ii)(C)(2) that, beginning January 1, 2026, if a payer-specific negotiated charge is based on a percentage or algorithm, the hospital must calculate and encode the 10th and 90th percentile allowed amounts in dollars for that item or service. We proposed to define “tenth (10th) percentile allowed amount” in Sec. 180.20 as the 10th percentile of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no longer than the 12 months prior to posting the MRF. We also proposed that if the calculated percentile falls between two observed allowed amounts, the 10th percentile allowed amount is the next highest observed value. We proposed to define “ninetieth (90th) percentile allowed amount” in Sec. 180.20 as the 90th percentile of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no longer than the 12 months prior to posting the MRF. We also proposed that if the calculated percentile falls between two observed allowed amounts, the 90th percentile allowed amount is the next highest observed value.

Comment: We received many comments in support of our proposals to replace the estimated allowed amount with the median allowed amount and to add the 10th and 90th percentile allowed amounts. Several commenters indicated they believe the median, 10th percentile, and 90th percentile allowed amounts would be more useful than the estimated allowed amount, better reflecting what hospitals have been reimbursed for items and services. One commenter indicated they believe the median allowed amount would provide a more “robust and nuanced picture” of negotiated charges within the MRF. One commenter indicated they believe the median, 10th percentile, and 90th percentile allowed amounts would enhance “data utility for researchers, innovators, purchasers, and consumers seeking to understand price variation across hospitals and payers in a market.”

Response: We thank commenters for their support of the proposals. As we discussed in the CY 2026 OPPS/ASC proposed rule (90 FR 33792 through 33793), and in agreement with commenters, we continue to believe that requiring the median, 10th percentile, and 90th percentile allowed amounts will provide greater context and clarity with respect to the payer-specific negotiated charge than the estimated allowed amount. The median, 10th percentile, and 90th percentile allowed amounts will further improve the public's ability to understand the actual price of care, particularly when making comparisons across hospitals. As we stated in the CY 2026 OPPS/ASC proposed rule, allowed amount data elements will help MRF users to develop patient-level solutions to aid in patient financial planning and decision-making. The availability of a range of reference points, including lower (10th percentile), median (50th percentile), and upper (90th percentile) allowed amounts, will better enable healthcare consumers to compare cost information across hospitals, empowering them to better manage budgets, avoid unexpected financial burdens, and make more fully informed and value-conscious health care choices.

Likewise, researchers, innovators, policy officials, employers, and others MRF users will be able to use the information to improve data analysis and more precisely model healthcare costs and cost estimation algorithms, provide insights into healthcare pricing dynamics, and gain a deeper understanding of price dispersion across contracts that might provide a basis for negotiation and advocacy to more effectively bargain with healthcare providers and payers to yield more competitive pricing. Furthermore, the 90th percentile allowed amount will be helpful for assessing financial risk and identifying cases where costs exceed typical ranges. This information could assist researchers and innovators in refining cost predictions and contribute to better risk management strategies. As stated in the CY 2026 OPPS/ASC proposed rule (90 FR 33794), we continue to believe that for consumers with insurance plans that include coinsurance and deductibles, the 10th and 90th percentile allowed amounts would provide critical potential lower and upper reference points for estimating out-of-pocket expenses.

Comment: We also received comments opposing our proposals to replace the estimated allowed amount with the median allowed amount and to add the 10th and 90th percentile allowed amounts. Many commenters questioned the value of replacing the estimated allowed amount with the median allowed amount and adding the 10th and 90th percentile allowed amounts, indicating that they saw no additional benefit in these proposals for patients. Several commenters indicated they believe that replacing the estimated allowed amount with the median allowed amount and adding the 10th and 90th percentile allowed amounts would “overwhelm” patients with information that is difficult to interpret. A few commenters maintained that patients are more interested in knowing what their out-of-pocket costs may be for an upcoming hospital visit than negotiated rates between hospitals and insurers, or what hospitals have been reimbursed for items and services. A few commenters indicated that requiring the median, 10th percentile, and 90th percentile allowed amounts in the MRFs may be misleading for patients who would look at this information as a representation of what they would be expected to pay should they receive that item or service at the hospital. Therefore, several commenters recommended that we focus on advancing tools and requirements that provide patients with individualized and accurate pre-service estimates that factor in cost- sharing amounts/coinsurance, patient progress toward meeting their deductible, co-payments, and other pertinent information.

Response: We disagree with commenters who indicated there is no value for patients in replacing the estimated allowed amount with the median allowed amount and adding the 10th and 90th percentile allowed amounts. As we stated in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82079), while the MRF format is designed to be used by innovators, employers and researchers and to be ingested into machines for further processing of the data, the information contained in a MRF is critical for driving competition and directly beneficial for patients. We believe, as discussed in the CY 2026 OPPS/ASC proposed rule (90 FR 33792 through 33793), that replacing the estimated allowed amount with the median allowed amount and adding the 10th and the 90th percentile allowed amounts will better enable price estimator tools to develop and estimate an individual's personalized out-of-pocket cost, as suggested by some commenters, ultimately providing patients with the information some

commenters stressed patients are most interested in and need.

Comment: Many commenters indicated that they oppose the proposals to replace the estimated allowed amount with the median allowed amount and add the 10th and 90th percentile allowed amounts due to the burden they place on hospitals. In particular, commenters expressed concerns about the specific instruction, in the definition of the median allowed amount and the 10th and 90th percentile allowed amounts, stating that should the calculated percentile “fall between two observed allowed amounts, the percentile allowed amount is the next highest observed value.” These commenters indicated this deviation from the standard way of calculating a percentile when it falls between two observed values would require hospitals to implement custom formulas for these calculations rather than the “out-of-the-box” formulas, increasing hospital burden. Several commenters requested that CMS not finalize these proposals due to resource constraints, particularly for small and rural hospitals, and a few commenters indicated the proposed effective date of January 1, 2026, would make complying with the requirements, if finalized as proposed, especially challenging. A few commenters requested we provide technical support and training for hospitals to assist them with implementing the requirements, should we finalize them as proposed. One commenter suggested we convene a group of stakeholders to evaluate how to display allowed amounts within the MRF and allow flexibility for hospitals to display their negotiated charges in the MRF as they deem appropriate until such time as the group could meet.

Response: We appreciate commenters' concerns that the proposed methodology for arriving at a value when the median, 10th percentile, or 90th percentile allowed amounts fall between two different values is not standard and may require additional programming or calculations by hospitals and this creates additional burden. However, as we stated in the CY 2026 OPPS/ASC proposed rule (90 FR 33792 through 33793), we believe the need to identify the actual dollar value a hospital has received is consistent with our statutory authority and aligns with the Administration's goals of ensuring pricing information is standardized and easily comparable across hospitals when a hospital's payer-specific negotiated charge is based on a percentage or algorithm.

As with previous HPT rulemaking, we will provide technical guidance and examples of how to encode the new data elements we are finalizing in this rule on the CMS Hospital Price Transparency--Data Dictionary GitHub Repository (https://github.com/CMSgov/hospital-price-transparency), as well as guidance on the HPT resources page on the CMS website (https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency/resources). We thank the commenter for their suggestion to convene a stakeholder group to evaluate the use and display of allowed amounts within the MRF and to continue to allow flexibility until we do, but decline the commenter's suggestion at this time as we believe we have received sufficient feedback on encoding allowed amounts within the MRF via the public comment period on the proposed rule as well as in response to the “CMS Hospital Price Transparency Accuracy and Completeness Request for Information” (the public comment period for which closed on July 21, 2025), in which commenters recommended hospital MRFs should list a precise dollar amount for items and services whenever possible.

Comment: Several commenters expressed concern about replacing the estimated allowed amount with the median allowed amount and adding the 10th and 90th percentile allowed amounts so soon after the January 1, 2025 effective date of the estimated allowed amount requirement. These commenters questioned why CMS believes the estimated allowed amount is insufficient to provide context to the payer-specific negotiated charge when it is based on a percentage or algorithm and why the median allowed amount is more useful to consumers of the MRF. One commenter questioned why our proposals in the proposed rule deviate from our May 22, 2025 guidance.

Response: As discussed in the CY 2026 OPPS/ASC proposed rule, on February 25, 2025, the President issued Executive Order 14221 directing that HHS act to require disclosure of actual prices and ensure pricing information is easily comparable across hospitals. Consistent with the Executive Order and the feedback we have received from interested parties, we have considered ways to improve the requirement for hospitals to make public actual dollar amounts in the MRF to further transparency and comparability of hospital pricing information. Specifically, we considered the usefulness of the estimated allowed amount, as defined at Sec. 180.20, in providing necessary context for the payer-specific negotiated charge and in facilitating comparisons across hospitals. As we stated in the proposed rule, we believe that the payer-specific negotiated charge should be better contextualized and more precisely encoded to improve the MRF users' ability to understand and use hospital standard charges. While the estimated allowed amount provides useful additional context and enhances transparency and comparability of hospital standard charges, the median, 10th percentile, and 90th percentile allowed amounts more accurately reflect what the hospital is reimbursed.

Our May 22, 2025 guidance regarding the use of the estimated allowed amount was an important first step towards requiring the disclosure of the actual prices of items and services, not estimates, and ensuring pricing information is standardized and easily comparable across hospitals and health plans. We realized, however, that additional requirements would be needed to achieve that aim. Toward that end, we proposed in the CY 2026 OPPS/ASC proposed rule to replace the estimated allowed amount with the median allowed amount and to add the 10th and 90th percentile allowed amounts, requiring hospitals to encode actual dollar values they have received for an item or service when the payer-specific negotiated charge is based on an algorithm or percentage. Consistent with the President's Executive Order and our goal of advancing the disclosure of the actual prices of items and services, we are finalizing our proposals to replace the estimated allowed amount with the median allowed amount and to add the 10th and 90th percentile allowed amounts.

Comment: Several commenters requested, as an alternative to our proposal to replace the estimated allowed amount with the median allowed amount and to add the 10th and 90th percentile allowed amounts, that CMS require hospitals, without exception, to make public all their payer-specific negotiated charges “in dollars and cents,” thus eliminating the need for the currently required estimated allowed amount or the proposed median, 10th percentile, and 90th percentile allowed amounts. These commenters indicated they believe this is the only way to be able to make “apples-to-apples” comparisons across hospitals and for patients to understand what they might be expected to pay for an item or service. One of these commenters suggested we prohibit hospitals from charging patients more than a payer-specific negotiated charge dollar amount and presume that any MRF that has payer-specific negotiated charges represented as percentages and algorithms is automatically non-compliant with our requirements.

Conversely, one commenter requested we indicate in the final rule that the allowed amounts would not represent a guaranteed price because they do not necessarily represent the amount an individual would expect to pay for the item or service.

Response: We point these commenters to the discussion in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82079) where we acknowledged and agreed with commenters that, although critical for determining an individual's out-of-pocket obligation, hospital standard charges do not represent either an individual's out-of-pocket obligation or a “real, guaranteed price.” However, as we noted in the CY 2024 OPPS/ASC final rule with comment period, individualized estimates in dollars may be obtained directly, in many circumstances, from providers and payers through other Federal price transparency efforts such as those implementing the NSA and TiC requirements. As such, we continue to strongly encourage individual consumers to avail themselves of hospital and payer price estimator and comparison tools, and to seek out “good faith estimates” from hospitals to comply with separate requirements implementing the NSA, which may provide up-front pricing that can be used to dispute final charges that are substantially in excess of the up-front amounts. Additionally, we reiterate, as we stated in the CY 2020 HPT final rule and the CY 2024 OPPS/ASC final rule with comment period, that we continue to encourage hospitals to provide consumers with cost information in a consumer- friendly manner. Furthermore, as we noted in the CY 2024 OPPS/ASC final rule with comment period, we understand the desire for individual patients to access hospital prices in dollars and cents. However, as discussed in that rule, we continue to disagree that all hospitals can produce a payer-specific negotiated charge in dollars that meets the definition of a “standard charge” because hospitals establish payer- specific negotiated charges in many ways, ranging from basic fee schedules (in which dollar amounts for specific items and services are known), to grouper methodologies (in which a base rate in dollars has been established but may then be modified depending on other factors like transfers or outliers), to “percent of billed charges” schemes (in which the dollar amount varies from person to person). Finally, as discussed in the CY 2024 OPPS/ASC final rule with comment period, we believe that section 2718(e) of the PHS Act directs the Secretary to tell hospitals how to display their standard charges, not how to establish them or that they must establish them.

We continue to believe that the policies we are finalizing in this final rule with comment period will greatly improve the transparency of payer-specific negotiated charges and will make such charges more comparable across hospitals.

Comment: A few commenters recommended CMS keep the requirement to encode the estimated allowed amount in the MRF instead of replacing it with the median allowed amount and adding the 10th and 90th percentile allowed amounts, indicating they believe that given the volume and complexity of the MRFs, the average would provide a more accurate estimate of what a hospital has historically received for that item or service. One commenter indicated that “the law of large numbers ensures that the sample mean will converge towards the true population mean as the sample size grows. This assures that with enough data, such as that contained in MRFs, the average provides a more accurate estimate of the overall characteristic of the population being studied.”

Response: We recognize that the extent to which a sample statistic provides a reasonable representation of the population statistic depends, at least in part, on the sample size. Therefore, we proposed hospitals encode the count of allowed amounts data element (described in a later section) so that consumers of the MRFs can make informed decisions about the data. The commenter did not provide additional reasons for why the mean is a preferred statistic to the median, 10th percentile, and 90th percentile allowed amounts. We provided our reasons for proposing hospitals encode the median, 10th percentile, and 90th percentile allowed amounts in the proposed rule. Specifically, we stated we believe these allowed amounts would be a more accurate reflection of the amount a hospital would be reimbursed for an item or service. Thus, we proposed to revise Sec. 180.50(b)(2)(ii)(C) to require hospitals to encode, beginning January 1, 2026, the median allowed amount, rather than the estimated allowed amount, if a payer- specific negotiated charge is based on an algorithm or percentage. We explained why the median allowed amount would be a more accurate and useful indicator of the allowed amount instead of a mean or average allowed amount with an outlier example in the proposed rule, that we reiterate here. [GRAPHIC] [TIFF OMITTED] TR25NO25.230

In the scenario detailed in Table 143, the mean of the claim remittance amounts is $35,000, which exceeds all the other values except for the $200,000 outlier and would not reasonably reflect the allowed amount for that item or service. By contrast, the $20,000 median would be a more accurate reflection of the allowed amount for that item and service and the amount a hospital typically would be reimbursed for that item or service. As we stated in the proposed rule, requiring the median rather than the average is consistent with generally accepted statistical principles for assessing the central point of a distribution when there are outliers.\453\

\453\ Cooksey, R.W. (2020). Descriptive Statistics for Summarising Data. In: Illustrating Statistical Procedures: Finding Meaning in Quantitative Data. https://doi.org/10.1007/978-981-15-2537-7_5. https://doi.org/10.1007/978-981-15-2537-7_5.

Comment: A few commenters requested clarification on, or seemed to misinterpret, our proposal to replace the estimated allowed amount with the median allowed amount. One commenter suggested regular changes in the gross charge will impact the calculation of the allowed amount. One commenter requested we clarify what a hospital should encode when they have no remittance data from which to calculate the median allowed amount. One commenter asked if CMS finalizes the proposals, would a hospital be required to encode the median, 10th percentile, and 90th percentile allowed amounts if they have encoded a payer-specific negotiated charge as a dollar amount.

Response: We thank commenters for the questions. We clarify that we proposed to define the median allowed amount as the median of the total allowed amounts the hospital has historically received from a third party payer. Since the median allowed amount would be based on the remittances received from a third party payer, we do not see how changes in the gross charge, which is defined in regulation as the charge for an individual item or service that is reflected on a hospital's chargemaster, absent any discounts, would impact the calculation of the allowed amounts. We also clarify that should a hospital have no remittance data for a particular item or service within the 12-to-15 month lookback period prior to posting the MRF (discussed in a later section), a hospital would encode “0” for the count of allowed amounts for that item and service and may leave the median, 10th percentile, and 90th percentile allowed amounts in the MRF blank. Further, we clarify that if a hospital has encoded a payer- specific negotiated charge in the MRF as a dollar amount, and that dollar amount represents the full payer-specific negotiated charge that is not further modified by a percentage or algorithm, the hospital would not be required to encode the allowed amounts. For example, if the hospital's payer-specific negotiated charge is 70 percent of the Medicare payment rate, then the hospital would calculate and encode the payer-specific negotiated charge as a dollar amount, and would not need to further describe the percentage or algorithm or provide the allowed amounts. If a payer-specific negotiated charge is a dollar amount and can be calculated, in part, but does not fully account for the payer- specific negotiated charge, however, then the hospital must calculate and encode the payer-specific negotiated charge dollar amount and must also describe the algorithm or percentage and encode the allowed amounts. For example, if the service has a base rate of $3,495, and is further modified by an algorithm, then the hospital would encode the base rate of $3,495 in the standard charge dollar data element, and then describe the algorithm that further modifies that base rate in the standard charge algorithm data element, and encode the allowed amounts. Figure 3 is an example of the information required for the algorithm description.

Comment: One commenter requested CMS reconsider in future rulemaking requiring hospitals to encode a “maximum allowed amount” that would reflect the maximum total allowed amount a hospital has historically received for a third party payer for an item and service.

Response: In the CY 2024 OPPS/ASC final rule with comment period (88 FR 82100), we stated that we agreed with commenters that the display of a maximum allowed amount could provide some clarity about the highest dollar amount a consumer might be obligated to pay (once the consumer calculates their own potential out-of-pocket obligation based on the displayed maximum allowed amount). For example, suppose, with respect to a particular payer and plan, the maximum allowed amount for an item or service was displayed as $1,500, the plan featured a 20 percent coinsurance requirement, and the individual had already met any applicable annual deductible. In such a scenario, the individual would likely not be required to pay more than $300 (20 percent of $1,500) for the indicated item or service.\454\

\454\ We note that this scenario is slightly different than we had portrayed at 88 FR 81540, 82101 which, in retrospect, we realized was erroneous with respect to the deductible.

At that time, however, we elected not to adopt commenters' suggestions to require hospitals to encode the maximum allowed amount because, as we stated, a maximum dollar value derived from past remittances or other data sources could include outliers, thereby potentially misrepresenting an individual's required payment for an item or service. As we indicated in the CY 2026 OPPS/ASC proposed rule (88 FR 82101), the display of the maximum allowed amount could be skewed to the point where it would not present useful information to consumers or the public. As opposed to the maximum allowed amount, however, the 90th percentile of the total allowed amounts for an item or service would be more representative of the dollar amount the individual might be responsible for paying, less subject to extreme outliers, and would provide an additional data point to contextualize the dollar value when the payer-specific negotiated charge for an item or service is based on a percentage or algorithm. Similarly, we stated we believe that setting a threshold based at the 10th percentile would exclude outliers on the low end, and, when combined with the other data elements, provide MRF users with a better understanding of the realistic range of payer-specific negotiated charges. We will continue to evaluate the utility of the maximum allowed amount, and may revisit this alternative in future rulemaking.

Final Action: After consideration of public comments, we are finalizing our proposals to replace the estimated allowed amount with the median allowed amount and to add the 10th and 90th percentile allowed amounts, including our proposed methodology for calculating the allowed amounts should the calculated percentile fall between two observed allowed amounts. As described earlier, we are revising Sec. 180.50(b)(2)(ii)(C) to require, at new Sec. 180.50(b)(2)(ii)(C)(2), that, beginning January 1, 2026, if a payer-specific negotiated charge is based on a percentage or algorithm, the hospital must calculate and encode the 10th percentile, median, and 90th percentile allowed amounts in dollars for that item or service, but delaying enforcement until April 1, 2026.

As noted previously, we also are finalizing, with modification, our proposed definition of “median allowed amount” in Sec. 180.20, such that the

“median allowed amount” will be defined as the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no less than 12 months and no longer than 15 months prior to posting the machine-readable file. We are finalizing, with modification, our proposed definition of “tenth (10th) percentile allowed amount” in Sec. 180.20 as the 10th percentile of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no less than 12 months and no longer than 15 months prior to posting the machine-readable file. We are finalizing, with modification, our proposed definition of “ninetieth (90th) percentile allowed amount” in Sec. 180.20 as the 90th percentile of the total allowed amounts the hospital has historically received from a third party payer for an item or service for a time period no less than 12 months and no longer than 15 months prior to posting the machine- readable file. We are also finalizing at Sec. 180.20 that should the calculated percentile fall between two observed allowed amounts (in other words, where the total count, n, is an even number), the allowed amount will be the next highest observed value. c. Calculation of Allowed Amounts (1) Determining the “Total Allowed Amount”

In the CY 2026 OPPS/ASC proposed rule (90 FR 33795), we noted that, under the proposed definitions of “median allowed amount,” “10th percentile allowed amount,” and “90th percentile allowed amount” at Sec. 180.20, hospitals would calculate the allowed amount considering the “total allowed amount” for an item or service. As with the estimated allowed amount in the current rule, and as we explained in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82101), the amount should reflect the total amount the hospital was reimbursed for the item or service (or service package). We stated in the CY 2026 OPPS/ASC proposed rule (90 FR 33795) that the “total allowed amount” dollar figure would be derived from the gross charge minus contractual adjustments and consist of the portion billed to a payer for a particular plan and the portion, if any, billed to the patient. As we indicated in the CY 2026 OPPS/ASC proposed rule, we believe defining the “total allowed amount” this way would help to enhance consistency in how hospitals calculate this contextual data element, increasing comparability across hospitals.

We received no comments about this provision and are finalizing as proposed. (2) Data Source for Calculating the Allowed Amounts

In the CY 2024 OPPS/ASC final rule with comment period (88 FR 82101), we stated our belief at the time that hospitals should retain flexibility, in the interest of reducing burden, to determine the best data source(s) for calculating the estimated allowed amount data element, though we agreed with commenters that using information from EDI 835 ERA transaction data would appear to meet our requirements. To enhance the consistency of hospital standard charge information and the comparability of the median allowed amount, and the 10th percentile and 90th percentile allowed amounts, and in accord with what commenters had earlier suggested in the CY 2024 OPPS/ASC final rule with comment period, in the CY 2026 OPPS/ASC proposed rule (90 FR 33476), we proposed to require that hospitals only use EDI 835 ERA transaction data to calculate and encode the allowed amounts. As we had indicated in prior rulemaking (88 FR 82100 through 82101), EDI 835 ERA transaction data, the electronic transaction data that provides claim payment information that hospitals use to track and analyze their claims and reimbursement patterns, including any adjustments made to the claim such as denials, reductions or increases to the amount charged, and expected patient co-payments, co-insurance, or secondary coverage, would meet the requirement to calculate an allowed amount. We sought comment on the proposal to require that hospitals only use EDI 835 ERA transaction data to calculate and encode the allowed amounts. We also sought comment on whether there are instances where a hospital would not have access to EDI 835 ERA transaction data and whether there are alternative data sources we should consider requiring hospitals to use to calculate the allowed amounts and count of allowed amounts.

Comment: Several commenters supported our proposal to require that hospitals only use EDI 835 ERA transaction data to calculate and encode the allowed amounts, indicating that the proposal would enhance comparability across hospitals and improve the utility of MRFs. One commenter indicated that the requirement would improve consumers' ability to “comparison shop” between hospitals as they will have confidence that the allowed amounts were calculated using common sources of data. Another commenter indicated that EDI 835 ERA transaction data is the “superior option” for calculating the allowed amounts and suggested that other data sources would be less reliable. One commenter maintained that EDI 835 ERA transaction data is an industry standard and the most comprehensive source of transaction data from which to calculate the allowed amounts and urged us not to deem any other data sources as a compliant alternative to EDI 835 ERA transaction data.

Response: We thank commenters for the support of our proposal to require that hospitals only use EDI 835 ERA transaction data to calculate and encode the allowed amounts. We agree with commenters that suggested EDI 835 ERA transaction data is sent by many payers and thus requiring its use to calculate and encode the allowed amounts would enhance the consistency of hospital standard charge information and the comparability of the median allowed amount, and the 10th percentile and the 90th percentile allowed amounts. However, as discussed in a later comment summary, several commenters indicated that there are scenarios in which a hospital does not have access to EDI 835 ERA transaction data. In order to ensure that all hospitals subject to the HPT requirements are able to calculate and encode the allowed amounts, we are requiring hospitals to use EDI 835 ERA transaction data or an alternative, equivalent source of remittance data that includes the same information as EDI 835 ERA transaction data would include (as discussed in more detail below).

Comment: Many commenters opposed our proposal to require that hospitals only use EDI 835 ERA transaction data to calculate and encode the allowed amounts due to the perceived burden of the proposal. Several commenters indicated that requiring hospitals to only use EDI 835 transaction data would require significant resource investment, coordination within the hospital, and, potentially, coordination with their EHR vendors. Several commenters maintained that it would be difficult to only use EDI 835 ERA transaction data to calculate and encode the allowed amounts because the data is not standardized, the data may not capture item or service level detail, payers use claim adjustment reason codes (CARC) and remittance advice reason codes (RARC) inconsistently, and payers frequently deviate from Health Insurance Portability and Accountability Act (HIPAA) standard transaction requirements. A few commenters suggested that using EDI 835 ERA transaction data to calculate

and encode the allowed amounts may be particularly difficult for small and rural hospitals with limited technical capacity.

Several commenters opposed the proposal to require hospitals to only use EDI 835 ERA transaction data to calculate and encode the allowed amounts because they indicated there are scenarios where a hospital does not have EDI 835 ERA transaction data. Several commenters noted that some payers still send paper remittances and a few commenters indicated that they have electronic remittance data from some payers, but it is not EDI 835 ERA transaction data. A few commenters indicated hospitals may lack direct access to EDI 835 ERA transaction data. A few commenters indicated that hospitals may receive reimbursement in the form of per month supplements, value-based payment distributions, or other payment arrangements that may not be reflected in EDI 835 ERA transaction data, and in such cases, one commenter suggested hospitals be allowed to reconcile EDI 835 ERA transaction data with other data sources to ensure the allowed amounts reflect the full reimbursement for a particular item or service. One commenter noted that CMS' proposal does not account for hospitals with integrated healthcare delivery systems which rely on internal allowed amount fee schedules as an alternative, equivalent data source and would produce the same allowed amount outputs as the EDI 835 ERA transaction data, but without significant administrative inefficiencies. Another commenter suggested that if a hospital does not have access to EDI 835 ERA transaction data, they support allowing the use of an alternative data source.

Response: We believe the requirements we are finalizing in this final rule with comment period will strengthen HPT through further standardization and comparability of the allowed amounts across hospitals, and that the benefits to the public outweigh the burden on hospitals. We appreciate commenters who suggested that there are reimbursements that may not be reflected in the EDI 835 ERA transaction data. Acknowledging the merits of these comments, we are finalizing that hospitals be required to use EDI 835 ERA transaction data or an alternative, equivalent source of remittance data that includes the same information as EDI 835 ERA transaction data would include. We clarify that if a hospital uses an alternative, equivalent source of remittance data to calculate and encode the allowed amounts, such data source must allow the hospital to calculate the “total allowed amount,” meaning the gross charge minus contractual adjustments, consisting of the portion billed to a payer for a particular plan and the portion, if any, billed to the patient. Further, as discussed in more detail in another section of this final rule with comment period, although the new requirements at Sec. 180.50 will be effective January 1, 2026, we are delaying enforcement of these requirements to April 1, 2026, to provide hospitals with more time to comply. We believe our finalized policy to give hospitals the option to use an alternative, equivalent source of remittance data that includes the same information as EDI 835 ERA transaction data is responsive to commenters' concerns about the lack of availability of EDI 835 ERA transaction data for certain hospitals and mitigates concerns of burden associated with accessing EDI 835 ERA transaction data for such hospitals. At the same time, acknowledging commenters' concerns about burden we have increased burden estimates in section XXIII. (Collection of Information Requirements) of this final rule with comment period.

Comment: Several commenters opposed our proposal to only use EDI 835 ERA transaction data to calculate and encode the allowed amounts because they disagree with the EDI data they have been provided by payers, or believe there are errors in the data they have received. A few commenters indicated that the allowed amounts encoded in hospitals' MRFs may be much lower than the payer-specific negotiated charge for those items and services if CMS finalizes the requirement to use only EDI 835 ERA transaction data, as hospitals may have ongoing payment disputes with payers at the time the MRF is updated. One commenter indicated it would be “unreasonable” to require hospitals to use EDI 835 ERA transaction data because hospitals lack control over the accuracy of the data.

Response: We disagree with the commenter that indicated it would be unreasonable for us to require hospitals to use EDI 835 ERA transaction data to calculate and encode the allowed amounts. As indicated by commenters that supported our proposal, many payers send EDI 835 ERA transaction data to hospitals and thus it would be a consistent and reliable source of data for hospitals to use to calculate and encode the allowed amounts. However, as indicated elsewhere in this section, we are finalizing requiring hospitals to use EDI 835 ERA transaction data or an alternative, equivalent source of remittance data that includes the same information as EDI 835 ERA transaction data would include. Additionally, we recognize that some remittance data initially provided to a hospital may be later adjusted for a variety of reasons that may modify the total allowed amount for an item or service. However, as discussed in the CY 2026 OPPS/ASC proposed rule (90 FR 33796), timely filing limits for claims vary by state and payer, with a typical range of 30 days to 12 months from the date of service.\455\ \456\ \457\ \458\ In addition, research suggests that many healthcare claims are adjudicated within 30 days.\459\ Therefore, we believe much of the remittance data hospitals will use to encode the allowed amounts will be finalized within 13 months, and that our finalized lookback period (discussed in a later section) that includes no less than 12 months and no longer than 15 months of data prior to posting the MRF should provide sufficient time for hospitals to receive corrected remittance data for most of the data that is used. We acknowledge that there may be some instances where the remittance data hospitals use to calculate and encode the allowed amounts may change after the MRF is posted, due to additional adjustments. However, we believe the need for hospitals to use more recent remittance data to enhance comparability outweighs the need to capture the final disposition on a claim.

\455\ Washington State Office of the Insurance Commissioner. What medical providers need to know about health insurance. https://www.insurance.wa.gov/what-medical-providers-need-know-about-health-insurance.

\456\ Texas Department of Insurance. (Last Updated on March 25, 2025) Prompt Pay FAQ. https://www.tdi.texas.gov/hprovider/ppsb418faq.html.

\457\ Centers for Medicare & Medicaid Services (CMS). (2011) Transmittal 2140: Changes to the Time Limits for Filing Medicare Fee-For-Service Claims. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2140cp.pdf.

\458\ 42 CFR 447.45(d)(1) https://www.ecfr.gov/current/title-42/part-447/section-447.45#p-447.45(d)(1).

\459\ Orszag, Peter and Rekhi, Rahul. Real-Time Adjudication for Health Insurance Claims. https://onepercentsteps.com/wp-content/uploads/brief-rta-210208-1700.pdf.

Comment: A few commenters provided alternative suggestions to or requested clarification of our proposal for hospitals to calculate and encode the allowed amounts using only EDI 835 ERA transaction data. One commenter questioned whether we are proposing to require hospitals to calculate and encode a payer-specific negotiated charge that is not based on a percentage or algorithm using EDI 835 ERA transaction data. One commenter recommended we publish a standardized guide for calculating the allowed amounts at an item or service

level. One commenter suggested we require hospitals to encode the date of the most recent chargemaster update and the weighted average percentage increase applied to gross charges since the date of last update.

Response: As indicated in the CY 2020 HPT final rule (84 FR 65551), the payer-specific negotiated charge is defined as the charge that a hospital has negotiated with a third party payer for an item or service. We clarified in that rule (84 FR 65534) that the payer- specific negotiated charge can be found in other parts of the hospital billing and accounting systems than the chargemaster, or in rate tables or the rate sheets found in hospital in-network contracts with third party payers indicating the agreed upon rates for the provision of various hospital services. Since EDI 835 ERA transaction data is the electronic transaction data from payers that provides claim payment information rather than the payer-specific negotiated charge for an item or service, we clarify that we would not expect, nor should hospitals use, EDI 835 ERA transaction data to encode their payer- specific negotiated charges. We thank the commenter for the suggestion to publish a standardized guide for calculating the allowed amounts at an item or service level, but given the variation in how hospitals contract for items and services, we believe we would be unable to develop a standardized guide for calculating the allowed amounts that would apply to all items and services offered by all hospitals. We thank the commenter for the suggestion to require hospitals to encode the date of the most recent chargemaster update and the weighted average percentage increase applied to gross charges since the date of last update. We may consider these suggestions for future rulemaking.

Final Action: After consideration of public comments, we are finalizing our proposal, with modification. We are finalizing the requirement that hospitals must use EDI 835 ERA transaction data or an alternative equivalent source of remittance data that includes the same information as EDI 835 ERA transaction data would include, to calculate and encode the allowed amounts for items and services based on a percentage or algorithm in the MRF. (3) Lookback Period for Calculating the Allowed Amounts

In the CY 2024 OPPS/ASC final rule with comment period, we declined to specify a lookback period for hospitals when calculating the estimated allowed amount. This flexibility was intended to reflect the variations in frequency and timing with which hospitals negotiate contracts with payers. The estimated allowed amount was intended to reflect the average reimbursement in dollars a hospital received. Our expectation was that hospitals would calculate the historical amount they received from a payer for an item or service based on the most recent reimbursement under that negotiated algorithm or percentage.

However, as we stated in the proposed rule, we have come to understand that if hospitals use substantially different lookback periods, particularly across multiple years, it could distort the allowed amounts, for example, because of pricing changes over time such as inflation, efficiencies, or the introduction of new products or services. Additionally, hospitals using varied lookback periods reduces comparability across MRFs.

As such, to help ensure that all hospitals calculate the allowed amount data elements consistently and calculate them based on the most recent reimbursements, we proposed to require that hospitals base the median allowed amount, the 10th and 90th percentile allowed amounts, and the count of allowed amounts (discussed in a later section) on EDI 835 ERA transaction data from no longer than 12 months prior to posting the MRF. We proposed that if the negotiated percentage or algorithm associated with the allowed amounts was only used for a portion of the 12-month time period prior to posting the MRF, the hospital would encode the median allowed amount, 10th and 90th percentile allowed amounts, and count of allowed amounts from the EDI 835 ERA transaction data for the portion of time that the percentage or algorithm was used. We proposed that if the negotiated percentage or algorithm associated with the allowed amounts was used for the entire 12-month time period prior to posting the MRF, the hospital would encode the median allowed amount, 10th and 90th percentile allowed amounts, and count of allowed amounts from the EDI 835 ERA transaction data for the entire 12-month time period prior to posting the MRF. We stated that a hospital may therefore need to use different lookback periods to calculate the allowed amounts for each payer, depending on when a contract was negotiated. We acknowledged that there may be situations where the EDI 835 ERA transaction data is not yet final or may change after the allowed amounts are encoded in the MRF due to additional adjustments being applied to a claim(s), so we clarified that the allowed amounts should be based on the EDI 835 ERA transaction data available at the time the MRF is updated.

We considered the efficacy of various lookback periods to calculate and encode the allowed amount data elements, and looked to research to help us gauge potential lookback periods for generating price data based on historic claims remittances.\460\ \461\ As we discuss below, we considered a 3- or 6-month lookback period, and requiring hospitals to use a rolling 12-month period prior to when the MRF posted.

\460\ National Academy for State Health Policy Palliative Care in Medicaid Costing Out the Benefit: Actuarial Analysis of Medicaid Experience, December 17, 2022 https://nashp.org/palliative-care-in-medicaid-costing-out-the-benefit-actuarial-analysis-of-medicaid-experience/.

\461\ Xie, Q.Y., Schreier, G., Hoy, M., Liu, Y., Neubauer, S., Chang, D.C.W., Redmond, S.J., & Lovell, N.H. (2016). Analyzing health insurance claims on different timescales to predict days in hospital. Journal of Biomedical Informatics, 60, 187-196. https://www.sciencedirect.com/science/article/pii/S1532046416000034.

We stated in the proposed rule that while a shorter lookback period (3- or 6-month) could be useful for accounting for recent healthcare trends and identifying quick changes in allowed amounts, with respect to less frequently provided items and services, we acknowledged that hospitals may not have any remittance data from such a short time period from which to derive the allowed amount data elements, which would result in numerous blanks in the MRF. Additionally, we noted that timely filing limits for claims vary by state and payer, with a typical range of 30 days to 12 months from the date of service, with some longer claim periods.\462\ \463\ \464\ \465\ \466\ \467\ Therefore, we stated that using a 3-month or 6-

month lookback period to derive the median, 10th percentile, and 90th percentile allowed amounts, and count of allowed amounts, could result in numerous blanks in the MRF for some items and services and would not accomplish our goal of providing MRF users with meaningful and comparable price data.

\462\ National Academy for State Health Policy. Palliative Care in Medicaid Costing Out the Benefit: Actuarial Analysis of Medicaid Experience, December 17, 2022 https://nashp.org/palliative-care-in-medicaid-costing-out-the-benefit-actuarial-analysis-of-medicaid-experience/.

\463\ Xie, Q.Y., Schreier, G., Hoy, M., Liu, Y., Neubauer, S., Chang, D.C.W., Redmond, S.J., & Lovell, N.H. (2016). Analyzing health insurance claims on different timescales to predict days in hospital. Journal of Biomedical Informatics, 60, 187-196. https://www.sciencedirect.com/science/article/pii/S1532046416000034.

\464\ Washington State Office of the Insurance Commissioner. What medical providers need to know about health insurance. https://www.insurance.wa.gov/what-medical-providers-need-know-about-health-insurance.

\465\ Texas Department of Insurance. (Last Updated on March 25, 2025) Prompt Pay FAQ. https://www.tdi.texas.gov/hprovider/ppsb418faq.html.

\466\ Centers for Medicare & Medicaid Services (CMS). (2011) Transmittal 2140: Changes to the Time Limits for Filing Medicare Fee-For-Service Claims. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2140cp.pdf.

\467\ 42 CFR 447.45(d)(1). https://www.ecfr.gov/current/title-42/part-447/section-447.45#p-447.45(d)(1).

After considering these alternative options, we proposed that the lookback period for the median allowed amount, 10th and 90th percentile allowed amounts, and count of allowed amounts (discussed in a later section) be based on EDI 835 ERA transaction data from no longer than 12 months prior to posting the MRF. As discussed previously, we proposed that if the negotiated percentage or algorithm associated with the allowed amounts was only used for a portion of the 12-month time period prior to posting the file, the hospital would encode the median allowed amount, 10th and 90th percentile allowed amounts, and count of allowed amounts from the EDI 835 ERA transaction data for the portion of time that the percentage or algorithm was used. We stated that limiting the lookback period to no more than 12 months prior to posting the MRF would be consistent with section 2718(e) of the Public Health Service Act that refers to “for each year,” and our regulations that require the MRF to be updated at least annually (Sec. Sec. 180.50(e) and 180.60(e)). Additionally, we stated that for most items and services, it would allow hospitals the ability to amass sufficient claims remittance data at the payer and plan level to encode a price. We stated that where a hospital's payer contracts were initiated or renegotiated in a lesser period than the previous 12 months, with respect to those contracts, we proposed that a hospital would apply whatever period of applicability existed. As noted above, under the proposal, hospitals may need to employ different lookback periods for payers and plans, depending on when a contract was negotiated. We indicated our belief that this approach would help achieve our goal of ensuring pricing information is standardized and easily comparable across hospitals when a hospital's payer-specific negotiated charge is based on a percentage or algorithm, as well as the purpose of Executive Order 14221 to promote disclosure of a real price. We solicited comment on our proposal to require that the lookback period for the median allowed amount, the 10th and 90th percentile allowed amounts, and count of allowed amounts be based on EDI 835 ERA transaction data from no longer than 12 months prior to posting the MRF.

Comment: A few commenters supported our proposal to require that the lookback period for the median allowed amount, the 10th and 90th percentile allowed amounts, and count of allowed amounts be no longer than 12 months prior to posting the MRF. A few commenters indicated that a shorter lookback period would result in numerous blanks in the MRFs. One commenter stated that our proposal would provide a reasonable amount of time without skewing the data by including long lookback periods which would not consider changes such as inflation over that time period.

Response: We thank commenters for their support of our proposal.

Comment: Many commenters expressed concern about the proposal. While most of these commenters supported the standardization of the lookback period, many commenters expressed concern with the 12-month timeframe. Several commenters noted that 12 months is not sufficient as hospitals typically pull the data several months before posting and have claims adjudication lags effectively meaning that hospitals will only be able to use 6 to 8 months of data. One commenter suggested allowing hospitals to select any contiguous 12-month period within the 24 months prior to posting the MRF to allow for delays in payer adjudication. One commenter suggested that CMS allow time for hospitals to incorporate payment data from only the final month of the 12-month lookback period into the MRF before publication. Several commenters recommended a lookback period of at least 18 months. One commenter recommended an 18-24 month lookback period.

Response: We thank commenters for their comments on our proposal. We believe it is important to standardize the lookback period to improve comparability across MRFs by eliminating variances due to different lookback periods, without distorting the data by including data from several years prior that do not account for inflation, efficiencies, or the introduction of new products or services. However, we understand commenters' concerns that requiring a lookback period of 12 months from the date the MRF is posted may not result in data that truly reflects 12 months. As several commenters stated, hospitals may pull the data to encode the allowed amounts several months prior to posting the MRF, thus eliminating those months from the data calculations. We agree with commenters that this would result in several months not being included in the data calculations, effectively shortening the 12-month lookback period. In light of these comments, we are finalizing, with modifications, our proposed lookback period.

We are modifying the proposed definitions of “median allowed amount,” “10th percentile allowed amount,” and “90th percentile allowed amount” at Sec. 180.20 to replace the phrase, “no longer than 12 months” with “no less than 12 months and no longer than 15 months,” thus requiring hospitals to use a lookback period of no less than 12 months and no longer than 15 months prior to posting the MRF. This modification solidifies our intent in the proposed rule to ensure hospitals calculate the allowed amount data elements over a more consistent time period and calculate them based on the most recent reimbursements to enhance comparability. As noted earlier, we agree with commenters that a 12-month lookback period from the date of posting of the MRF may eliminate several months of data if hospitals pull the data a few months prior to posting. We believe the modifications we are finalizing to the lookback period help to address this concern by allowing a longer lookback period in situations where hospitals need time to pull and prepare data prior to posting the MRF. We expect hospitals to use at least the most recent 12 months of data that are available to them. However, in the case where hospitals need additional time to pull or prepare the data before posting the MRF, hospitals may use data from up to 15 months prior to the date the file is posted to help ensure they have adequate data to encode the allowed amounts. We agree with commenters that using a shorter, static 12-month period to derive the data could result in less information. We believe these modifications will result in hospitals encoding 12 months of data for all allowed amounts, striking a balance of fewer blanks in the files with meaningful data. We note that nothing precludes a hospital from using 15 months of data to encode the “median allowed amount,” “10th percentile allowed amount,” and “90th percentile allowed amount.”

Comment: Several commenters stated that a 12 month-lookback period may not be enough time for a meaningful count when the hospital has recently negotiated or renegotiated a contract or an item or service is rarely performed or newly introduced. A few commenters pointed out that, as proposed, there will be varying amounts of data available as hospitals negotiate contracts at different times. A few commenters noted the complexity of a segmented lookback

period if a contract changes midyear or if there are multiple allowed amounts that vary as a result of a lookback period that includes a contract change. One commenter requested clarification on whether hospitals should limit the claims utilized in cases where a contract has become effective within the 12-month window. Another commenter requested clarity on what defines the threshold of a change in a contracted amount.

Response: We agree with commenters that a 12-month lookback period for data to encode the “median allowed amount,” “10th percentile allowed amount,” and “90th percentile allowed amount” may not be enough for a meaningful amount of data when the hospital has recently negotiated or renegotiated a contract, or an item or service is rarely performed or newly introduced. We believe the modifications we are finalizing to the lookback period help to address this concern by providing a longer period to amass adequate data to encode a value. As we discussed earlier, we also believe a more standardized lookback period will improve comparability across MRFs. A lookback period of no less than 12 months and no longer than 15 months prior to posting the MRF, as described in more detail earlier in this section, provides for a more consistent lookback period across hospitals than a static 12- month lookback period, which we believe helps to alleviate commenters' concerns about having varying amounts of data from which to encode the allowed amounts for an item or service and the complexity of a segmented lookback period if a contract changes midyear. We agree with commenters that the proposed requirement may have allowed instances where hospitals could have very short lookback periods and a lack of data depending on when a contract was negotiated or renegotiated. We believe that our finalized requirement will address this issue. We agree with commenters that it is important for hospitals to have a lookback period of at least 12 months prior to posting the file to provide MRF users with meaningful and comparable data, and that this may require additional flexibility. As such, and in response to these comments, we clarify that hospitals should report data from both prior to and after a contract negotiation date to capture a full 12-month period regardless of when the contract negotiation takes place. In the event that hospitals renegotiate a contract during the lookback period, hospitals should use data from both prior to and after the negotiation date and encode one figure for each of the allowed amount data elements. Regardless of how many times a contract was modified or the amount changed, the hospital should use all data available over a 12- month lookback period. We are making this change to address commenters' concerns that only including data from the most recent contract negotiation date would limit the amount of data used to encode allowed amounts.

Comment: A few commenters opposed our proposal. A few commenters requested that CMS retain the current requirements which allow hospitals the flexibility to use a lookback period of their choosing from which to encode the allowed amounts. One commenter expressed concern that the proposal will significantly increase the administrative burden on hospitals as the commenter believes it is a complex approach. A few commenters expressed concern that this requirement could require heavy manual analytics to view which rate codes changed during the course of the year at the contract level and extract those specific values.

Response: We appreciate commenters' concerns; however, as we stated in the proposed rule, the current flexibility has resulted in distorted allowed amounts because of pricing changes over time such as inflation, efficiencies, or the introduction of new products or services and reduced comparability across MRFs. By standardizing the lookback period, we believe we are simplifying the process and decreasing the amount of manual work needed to encode the allowed amounts. In particular, if a hospital renegotiates a contract during the lookback period, the hospital will include data from both before and after the renegotiated contract. We believe that this mitigates the additional burden mentioned by commenters about requiring analytics to view which rate codes changed during the course of the year and extract those specific values. We also believe the benefit of the modification we are finalizing to require hospitals to use a lookback period of no less than 12 months and no longer than 15 months prior to posting the MRF outweighs any burden that hospitals may experience, as users of the MRF will be able to better understand and use the data.

Comment: A few commenters offered additional suggestions with respect to this proposal. One commenter suggested that because it will be difficult for MRF users to know how many months of EDI 835 ERA transaction data were used in the allowed amount calculations, hospitals should also be required to encode the effective date of the contract in the MRF. Another commenter recommended an option by which a hospital could leave the field blank if it had less than 6 months of data available. One commenter suggested requiring hospitals to update their files every 6 months to ensure the most recent and complete data is provided and to minimize the number of blanks when hospitals have no historical claim remittance data.

Response: We thank commenters for providing additional suggestions with respect to this proposal, and, as we have explained, we are finalizing modifications to the proposal that we believe address several commenters' concerns. Our intent is to standardize the lookback period to improve comparability without distorting the data with a longer lookback period or creating unnecessary blanks in the MRF with a shorter lookback period. We believe our finalized lookback period of no less than 12 months and no longer than 15 months prior to posting the MRF strikes the right balance. We note that nothing precludes a hospital from adding additional information in the “Additional Notes” field, such as the effective date of the contract.

Final action: After consideration of public comments, we are finalizing our proposal with modification. We are finalizing that the lookback period for the median allowed amount, the 10th and 90th percentile allowed amounts, and count of allowed amounts is a time period of no less than 12 months and no longer than 15 months prior to posting the MRF. As such, we are revising the definitions of “median allowed amount”, “10th percentile allowed amount”, and “90th percentile allowed amount” at Sec. 180.20 to reflect a lookback period of no less than 12 months and no longer than 15 months prior to posting the MRF. We expect hospitals to use at least the most recent 12 months of data that is available to them. However, in the case where hospitals need additional time to pull or prepare the data before posting the MRF, hospitals may use data from up to 15 months prior to the date the MRF is posted to help ensure they have an adequate number of data points to encode the allowed amounts. The 12 to 15 months of data must be contiguous. In the event that a hospital renegotiates a contract during the 12- to 15-month span, the hospital must include data from both prior to and after the negotiation date. d. Hospitals To Encode the Count of Allowed Amounts

As part of our proposal to require hospitals to encode the median, 10th

percentile, and 90th percentile allowed amounts if a hospital's payer- specific negotiated charge is based on an algorithm or percentage, we also proposed to require hospitals to encode the count of allowed amounts from the EDI 835 ERA transaction data used to calculate the median, 10th percentile, and 90th percentile allowed amounts. We proposed that the same count of allowed amounts would be used to calculate the median, 10th percentile, and 90th percentile allowed amounts (90 FR 33797). We solicited comment on our proposed revision to Sec. 180.50(b)(2)(ii)(C) to require hospitals to calculate and encode the count of allowed amounts used to calculate the median, 10th percentile, and 90th percentile allowed amounts, as well as on our proposal that hospitals encode this data element with the actual number of allowed amounts used within the EDI 835 ERA transaction data. We also solicited comment on the alternative we considered of encoding the count of allowed amounts using a standardized range of the number of allowed amounts used within the EDI 835 ERA transaction data, rather than the actual number of allowed amounts, and sought comment on standardized range values of counts of allowed amounts that would be useful. In our proposal, we indicated our belief that this data element would also help drive understanding of the accuracy and completeness of the file, where applicable, and we also proposed that hospitals would be required to disclose why they were unable to calculate the median, 10th percentile and 90th percentile allowed amounts based on a lack of EDI 835 ERA transaction data.

Comment: Several commenters expressed their support for hospitals to encode the count of allowed amounts that were used to calculate the median, 10th percentile, and 90th percentile allowed amounts when the payer-specific negotiated charge is based on a percentage or algorithm. A few commenters indicated that the median, 10th percentile, and 90th percentile allowed amounts need to be interpreted in the context of the number of cases (or quantities) for which each procedure is performed and that disclosing the count of allowed amounts would help MRF users establish the credibility of this data, while further noting the policy aims to improve the accuracy and usability of the pricing data that hospitals must report.

Response: We thank commenters for their support of this proposal. We believe this additional context regarding the number of values used to calculate the median, 10th percentile, and 90th percentile allowed amounts--because more price volatility might reasonably be anticipated with respect to a less frequently performed service--would help MRF users determine whether allowed amounts are reasonably good approximations of what typically would be generated by the payer- specific negotiated charge percentage or algorithm. Knowing the number of allowed amounts used to derive the allowed amounts will better enable MRF users to assess how representative the median, 10th percentile, and 90th percentile allowed amounts are of the overall price distribution for the item or service.

Comment: A few commenters did not support the proposal to add the count of allowed amounts, citing the additional burden to encode this data from EDI 835 ERA transaction data.

Response: We acknowledge comments that cited the additional burden to calculate the count of allowed amounts used when calculating the median, 10th percentile, and 90th percentile allowed amounts, derived from EDI 835 ERA transaction data. In response to these comments, we have increased burden estimates, and as addressed above, have allowed additional flexibility to use an alternative, equivalent source of remittance data to address those concerns. As we stated in the CY 2026 OPPS/ASC proposed rule, we believe that requiring hospitals to encode the count of allowed amounts provides valuable information to allow MRF users to assess how representative the median, 10th percentile, and 90th percentile allowed amounts are of the overall price distribution for the item or service, with the reassurance of their statistical validity increasing with the increasing number of allowed amounts used to make the calculation. We believe that the benefit to the public to be able to understand the amount of data or number of remittances used to determine the allowed amounts outweighs the additional burden incurred by hospitals in encoding the count of allowed amounts. Additionally, as described in more detail later in this final rule with comment period, we are delaying enforcement of these new requirements to April 1, 2026 to allow hospitals additional time to implement the requirements.

Comment: Many commenters expressed concerns that, for low-volume services-- especially in rural settings-- the requirement to encode the count of allowed amounts could mean publishing very small claim counts that risk disclosure of protected health information and conflict with long-standing CMS and Federal data suppression standards. Commenters stated that publishing such small counts would not only raise HIPAA concerns but could also allow MRF users to back into sensitive information. A few commenters provided alternative approaches to address privacy concerns, including masking counts under either 10 or 11 by encoding an indicator such as “https://resdac.org/articles/cms-cell-size-suppression-policy.

We also acknowledge that, in certain situations (for example, in the case of a new hospital, or a hospital contracting with a new payer organization), a hospital may have no historical claim remittance history from which to derive a median, 10th percentile, or 90th percentile allowed amount for a payer and plan. We discussed this in the proposed rule (90 FR 33797), albeit with respect to a 12-month, as opposed to a 12- to 15-month, lookback period. Should a hospital have a “0” count of allowed amounts from the 12- to 15-month lookback period prior to posting

the MRF from which to derive the allowed amounts for a particular item or service, we are finalizing that it: (1) must encode “0” as the value for the count of allowed amounts for a specific payer and plan; (2) leave blank the associated MRF median, 10th percentile, and 90th percentile allowed amounts given there is no applicable data to encode; and (3) must encode information to explain the hospital's insufficient claim remittance history in the additional notes data element. In particular, should a hospital have no claims for the payer, we are requiring that a hospital encode why there is a “0” count of allowed amounts in the additional notes data element. We also note that nothing would preclude a hospital from updating its MRF when it has one or more remittances for an item or service. We also require that hospitals exclude zero-dollar claims from the count of allowed amounts because, as we noted in the proposed rule (90 FR 33797), they would result in a misleading and skewed calculation of the median, 10th percentile, and 90th percentile allowed amounts. Zero-dollar claims are health care claims submitted by the hospital to a payer organization where the payment amount is zero. Hospitals submit claims that result in no payment for some items and services because they provide information for the payer to calculate and process payment for the mix of services furnished, not because it results in a separate payment for that item or service. We appreciate the alternative suggested by one commenter that CMS only require the 10th and 90th percentile allowed amount values when counts are 11 or greater, but disagree as we would err on the side of the completeness of the MRF and the data encoded within.

Comment: One commenter stated, in response to the alternative we considered to encode the count of allowed amounts as ranges rather than a precise count, that requiring a range would present unnecessary burden to hospitals; thus, this commenter supported finalizing a precise count in the final rule.

Response: We agree with the commenter that our proposal offers greater precision and information, and reduces the burden on the hospital to encode the count of allowed amounts data element as a range.

Final action: After consideration of the comments received, we are finalizing at new Sec. 180.50(b)(2)(ii)(C)(2) that if the payer- specific negotiated charge is based on a percentage or algorithm, the hospital must calculate and encode the total number of allowed amount remittances from the EDI 835 ERA transaction data or an alternative, equivalent source of remittance data used to calculate the median, 10th percentile, and 90th percentile allowed amounts. Should the total count of allowed amount remittances be greater than 0 but less than 11, or 1 through 10, a hospital must indicate that at least 1 but no more than 10 allowed amount remittances were used in the calculation, using the valid value described in the CMS Hospital Price Transparency--Data Dictionary GitHub Repository website. We refer readers to section XIX.B.4.c.(2) of this final rule with comment period for discussion of the remittance data we are requiring hospitals to use to determine the count of allowed amounts. Should a hospital have a “0” count of allowed amounts within their remittance data from the 12- to 15-month lookback period from which to derive the allowed amounts for a particular item or service, we are finalizing that it: (1) must encode “0” as the value for the count of allowed amounts for a specific payer and plan; (2) leave the median, 10th percentile, and 90th percentile allowed amounts in the MRF blank as there is no data to encode; and (3) must encode information to explain the hospital's insufficient claim remittance history in the additional notes data element using the examples provided in the Hospital Price Transparency--Data Dictionary GitHub Repository. We also require that hospitals exclude zero-dollar claims from the count of allowed amounts. 5. Modification to the MRF Affirmation Statement

We proposed to supplant the existing affirmation requirement by, instead, specifying at new Sec. 180.50(a)(3)(iii) that, beginning January 1, 2026, hospitals will be required to attest in their MRFs to the following statement: “The hospital has included all applicable standard charge information in accordance with the requirements of Sec. 180.50, and the information encoded is true, accurate, and complete as of the date in the file. The hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.” We also proposed at new Sec. 180.50(a)(3)(iv) that, beginning January 1, 2026, the hospital must encode within the MRF the name of the hospital chief executive officer, president, or senior official designated to oversee the encoding of true, accurate and complete data as directed in Sec. 180.50(a)(3)(iii).

We stated in the proposed rule (90 FR 33798) that since the proposed new attestation requirements at Sec. 180.50(a)(3)(iii)-(iv) would supplant, with significantly stronger provisions, certain existing requirements, we believe those particular existing requirements would become superfluous and proposed to remove them. Provisions that we proposed to remove, effective December 31, 2025, include the affirmation requirement now at Sec. 180.50(a)(3)(ii) and the requirement at Sec. 180.50(a)(3)(i), which states that, beginning January 1, 2024, each hospital must make a good faith effort to ensure that the standard charge information encoded in the MRF is true, accurate, and complete as of the date indicated in the MRF. Specifically, we stated that we believe the attestation requirement we proposed would not only incorporate those concepts, but, in fact, would mandate significantly heightened hospital recognition of their responsibilities than what we presently require. We stated that we believe our proposed attestation requirements, if finalized as proposed, would reduce public confusion related to whether all standard charges for hospital items and services, where possible, are included within the MRF as dollar amounts. Additionally, we stated that, should our proposal be finalized as proposed, it would establish that the hospital has provided all available information to enable the public to derive a dollar amount, including, but not limited to, the specific fee schedule or components referenced in a percentage, algorithm or formula. We explained that we believe this would provide the necessary reassurance that hospitals have provided in their MRFs meaningful, accurate information to MRF users about their standard charges for health care items and services in order for those users to fully realize the intended use of the MRFs as expressed in the CY 2020 HPT final rule--that is, for enhancing the public's ability to use the data in, for example, innovator developed consumer tools and in EHRs at the point of care for value-based

referrals, or to aggregate and use the data to increase competition.

We stated in the proposed rule (90 FR 33799) that requiring an individual's name be specified would also, we believe, expedite our ability to quickly identify an individual at the hospital to obtain, where necessary, further clarity regarding the MRF data. In connection with this proposed requirement, we proposed to add a new general data element, attester name, and stated that, should the proposal be finalized as proposed, we would provide, on the CMS Hospital Price Transparency--Data Dictionary GitHub Repository website, instruction on how to encode this data element.

We also sought comment on an alternative approach, that is, whether CMS should require hospitals to post on their publicly available websites that host the hospital MRF, a standalone attestation document that would be signed by a hospital senior official. We received public comments on these proposals.

Comment: Several commenters supported the proposal to strengthen the current HPT requirements by replacing the “affirmation” standard with a more robust “attestation.” These commenters agreed that hospitals should attest that they have included all applicable payer- specific negotiated charges that can be expressed in dollars, and for charges not knowable in advance or that cannot be expressed as a dollar amount, hospitals should be required to include in the MRFs all necessary information available to enable the public to derive the dollar amount--such as the specific fee schedule or components referenced in any percentage, algorithm, or formula. A few commenters appreciated the proposal to rescind existing requirements that a hospital merely make a “good faith effort” to ensure their MRF data are true, accurate, and complete. One commenter expressed specific support for the removal of the phrase “to the best of their knowledge” from the proposed attestation statement. One commenter stated that without such attestation, hospital accountability for encoding accurate and complete data does not exist and the new requirement will demonstrate to the public that the Federal government and hospitals take seriously their obligation to provide accurate, reliable, actionable prices. One commenter underscored the requirement that hospitals must provide all necessary information for an average patient to determine the dollar amount without third-party assistance.

Response: We appreciate commenters' support for the proposed attestation statement. We proposed to adopt this attestation to make clear to hospitals and MRF users our expectations that the hospital will accurately and completely encode all available standard charge information. If the hospital established a payer-specific negotiated charge as a dollar amount, the hospital must display the payer-specific negotiated charge as a dollar amount. If the hospital is unable to display a payer-specific negotiated charge solely as a dollar amount, such as when the payer-specific negotiated charge is further modified by a percentage or algorithm, the hospital will be required to provide all necessary information available to the hospital to derive a dollar amount. We intend this public declaration to establish for MRF users and for CMS actionable certainty on the accuracy and completeness of the standard charge information displayed. We also intend that this public declaration will increase hospital accountability to MRF users that the data is complete as of the date indicated in the file. We believe demonstrating our strengthened expectations will result in the public display by hospitals of more meaningful data for MRF users. We agree with commenters that supported our removing the good faith effort provision, as this statement did not provide adequate assurances that all standard charge information was encoded in the MRF.

As discussed in more detail later in this section, we are finalizing the proposed attestation requirement, but with modification to retain the current phrase, “to the best of its knowledge and belief.” We appreciate the comment that patients will use the MRF to be able to understand the dollar amount for an item or service, but caution that the standard charge information encoded within the MRF reflects the standard charge, or the regular rate established by the hospital for an item or service provided to a specific group of paying patients, which is not necessarily reflective of an individualized charge for an episode of care. We encourage patients to use the HPT consumer-friendly display files and tools and the TiC tools that take into consideration the patient's plan design and avail themselves of the protections provided under the NSA, in order to obtain an individualized charge for their care.

Comment: Many commenters opposed the proposed attestation language, in particular, the phrase “has provided all necessary information available to the hospital for the public to be able to derive the dollar amount.” Many commenters stated that the proposed attestation fails to account for the reality of hospital billing, which they stated depends, in significant part, on insurer behavior and calculations which in turn depend on a host of factors that cannot be easily calculated by a third party, such as whether the service was provided in conjunction with other services, the applicability of any volume discounts or stop loss amounts, as well as other unique features of a patient's insurance plan. Commenters also noted that inpatient hospital reimbursement is typically based on an entire treatment case rather than a single service as well as on patient acuity, and stated that in many cases all the procedures that may be required cannot be known in advance. Several commenters stated that the phrase “has provided all necessary information available to the hospital for the public to be able to derive the dollar amount” incorrectly assumes that a member of the public is (1) capable of prospectively anticipating their every need during an episode of care; and (2) has the specialized knowledge and understanding of processes and nuances that underly hospital billing, coding, and reimbursement and can accurately use the algorithms displayed. Commenters stated that there will always be some additional piece of information that an individual could use to more accurately calculate a particular charge and noted that hospitals can never be entirely certain that they have provided “all necessary information . . . for the public to be able to derive the dollar amount.” In addition, commenters stated that publicizing negotiated rates and frameworks or even the full text of every single payer contract would not be sufficient to enable a patient to calculate their final bill, noting that because of insurers' penchant for proprietary systems and calculations, there may be nuances that are not readily available to or shareable by hospitals.

Several commenters further expressed concern that the proposed attestation language appears to require hospitals to guarantee the absolute accuracy of complex data and apply a strict liability standard and were concerned about the practicality of expecting flawless MRF data given the volume and complexity of hospital contracts and payment arrangements. Several commenters noted that the proposed median, and 10th and 90th percentile, allowed amounts are based exclusively on EDI 835 ERA transaction data which are developed by the payer and that hospitals do not have control over the accuracy and completeness of this data. Commenters stated that it would be unreasonable to hold hospitals accountable for validating and attesting

to the accuracy and completeness of data developed by a third party. One commenter noted that individual patient cost data requires detailed information not necessarily within hospitals' control (for example, payer algorithms, plan features, etc.). A few commenters also expressed concern that the proposed attestation that the hospital “has provided all necessary information available to the hospital for the public to be able to derive the dollar amount” risks ensnaring hospitals and health systems in a trap: since hospitals are unable to provide this detailed information, they cannot meet the new requirements of the attestation.

Given this, many commenters recommended retaining the existing “good faith effort” affirmation and the phrase “to the best of the hospital's knowledge and belief,” which they stated reflects what hospitals can realistically provide without raising the risk of liability for the failure to identify every single piece of information (“all”) that may exist. One commenter stated specifically that this is the most responsible option given the complexity of hospital price transparency reporting and the structural limits on the data hospitals receive from payers, and asserted that these qualifying phrases represent bona fide, reasonable commitments to integrity and transparency which are commonly used in legal certifications and affirmations. One commenter specifically asked that CMS include the language, “available information to best of our knowledge.” A few commenters stated that, at the very least, the agency must clarify the reasonable scope of “all necessary information.”

A few commenters stated that, because it would be impossible for hospitals to unilaterally provide sufficient information to enable patients to undertake these calculations on their own, the proposed attestation requirement would be arbitrary and capricious. Some of these commenters asserted that the imposition of an impossible requirement is, by definition, arbitrary and capricious and cited case law to support this belief. A few commenters further stated that at the very least, CMS' failure to consider the operability of this requirement would be arbitrary and capricious, with one commenter again citing case law to support their position.

Response: In the CY 2020 HPT final rule we asked hospitals to display their standard charges, and, subsequently, we encountered many MRFs strewn with blanks as hospitals indicated they could not display their charges as a dollar amount. In the CY 2024 OPPS/ASC final rule with comment period, based on hospital statements that many hospitals could not calculate a payer-specific negotiated charge as their payer- specific negotiated charge was based on a percentage of billed charges or based on a formula or algorithm that may be determined after the episode of care, we finalized new data elements, the payer-specific negotiated charge percentage and the payer-specific negotiated charge algorithm, to provide MRF users with an understanding of how the payer- specific negotiated charge was calculated, and a contextual data element, the estimated allowed amount, which is a dollar amount reflecting the average of the historical reimbursement (allowed amount) received from a third party payer for an item or service, required to be displayed when no payer-specific negotiated charge dollar can be encoded. We allowed hospitals the flexibility to describe their algorithms. Some hospitals met these additional requirements by providing additional data that gave MRF users valuable understanding on how the payer-specific negotiated charge is calculated and enough information that innovators, employers, and researchers could then draw meaningful comparisons. But other hospitals continued to provide opaque descriptions of algorithms with no anchor to help MRF users understand the calculation, sometimes using nine 9s in the estimated allowed amount field,\469\ and with some indicating they did not have enough claims data to calculate any estimated allowed amounts for any items or services in their MRF. We are issuing this fourth final rule to reiterate, and further, our goal of ensuring that pricing information is standardized and easily comparable across hospitals. In this final rule with comment period, we reinforce our requirement that hospitals must calculate and encode a payer-specific negotiated charge dollar amount when possible and, when the payer-specific negotiated charge is based on an algorithm or percentage, must do more than merely offer a good faith effort to enter their payer-specific negotiated charge percentage or algorithms; instead, hospitals must provide MRF users with a detailed explanation, when the payer-specific negotiated charge is based on a percentage or algorithm, of how the payer-specific negotiated charge is derived. In this rule, we describe the data source to be used to calculate the allowed amount data elements, providing flexibility on the lookback period to calculate the data, and attempting, again, to provide MRF users more fulsome data.

\469\ We acknowledge that, in past guidance, we established the use of the “nine 9s” policy. See https://www.cms.gov/files/document/cms-hpt-webinar-10-21-2024.pdf. (“CMS recommends that the hospital encode 999999999 (nine 9s) in the data element value to indicate that there is not sufficient historic claims history to derive the estimated allowed amount, and then update the file when sufficient history is available.”). Later recognizing that was a suboptimal approach, however, in subsequent guidance dated May 22, 2025, we said that “[h]ospitals should discontinue encoding 999999999 (nine 9s) in the estimated allowed amount data element within the MRF and should instead encode an actual dollar amount”. https://www.cms.gov/files/document/updated-hpt-guidance-encoding-allowed-amounts.pdf.

We disagree with commenters who stated that it is impossible for hospitals to comply with our requirements. We understand that hospitals may not know plan design, payer-based algorithms, or patient acuity, that are determined after the episode of care is complete, and also understand that an MRF in JSON or CSV that captures standard charge information at the item or service level cannot possibly account for every patient scenario. But we remind commenters that an MRF represents a point in time--as of the date in the file--and require that hospitals attest that the information therein is accurate and complete. We require that hospitals calculate a payer-specific negotiated charge in a dollar amount, and, if the hospital cannot, that it provide all the information “available to the hospital,” which would include information in the hospital's systems and payer contracts, in a way that a reasonable MRF user can understand.

We understand that some data is provided to hospitals from payers, and that hospitals cannot vouch that the EDI 835 ERA transaction data provided by the payer is accurate and complete, but hospitals can attest that their calculations of the allowed amounts follow the requirements specified within this regulation completely and accurately. We likewise understand that hospitals cannot provide everything that everyone might need to know, because such information may not be available to them, but we expect them to provide sufficient and necessary information that is available to them for a reasonable objective person to derive the price for an item or service. Through this final rule with comment period, we are requiring hospitals to take the steps necessary to provide all information available to the hospital, including in their systems and contracts, to support the public to be able to derive the dollar amount. Provided here are some examples.

If the payer-specific negotiated charge is based on 115 percent of the Medicare allowed amount, the hospital is required to perform the necessary calculations

and encode the payer-specific negotiated charge dollar amount. If the payer-specific negotiated charge is based on 87 percent of total billed charges, when the payment reflects the total of all charges provided at the time of the service, the hospitals should encode 87 in the payer- specific negotiated charge percentage data element and then calculate the 10th percentile, median, and 90th percentile allowed amount data elements in dollars so that MRF users can use that data to draw comparisons.

The HPT regulations state that if the payer-specific negotiated charge is based on a percentage or algorithm, the MRF must also describe the percentage or algorithm that determines the dollar amount for the item or service, and, beginning January 1, 2025, calculate and encode an estimated allowed amount in dollars for that item or service. For payer-specific negotiated charges based on algorithms and payment formulas, we believe that all necessary information means all factors that comprise an algorithm that determines how the payer-specific negotiated charge is derived should be encoded in the MRF. Examples include, but are not limited to, patient demographics, hospital demographics, clinical characteristics, length of stay, resource utilization, and adjustments based on mix of services performed.

Figure 1 is an example of where a hospital provides all the contractual data on how the price is calculated, but in a way that a reasonable, objective MRF user would not be able to interpret it and use it to draw comparisons; therefore, Figure 1 illustrates an approach that would not meet the regulatory requirements:

Figure 1: Example of an Unacceptable Payer-Specific Negotiated Charge Algorithm [GRAPHIC] [TIFF OMITTED] TR25NO25.231

Figure 2 provides an example where a hospital provides an algorithm that provides adequate context so that an MRF user may be able to replicate the formula to derive a price.

Figure 2: Example of an Acceptable Payer-Specific Negotiated Charge Algorithm [GRAPHIC] [TIFF OMITTED] TR25NO25.232

Figure 3 provides an example where the case rate is encoded as a payer-specific negotiated dollar amount, and then further modified.

Figure 3: Example of an Acceptable Payer-Specific Negotiated Charge Algorithm [GRAPHIC] [TIFF OMITTED] TR25NO25.233

We will provide additional examples in the CMS Hospital Price Transparency Data Dictionary GitHub Repository.

We have also observed that some hospitals provide their contractual language in the payer-specific negotiated charge dollar data element and provide additional useful descriptions of what the contractual language includes using one of the additional notes data elements provided. Nothing would preclude a hospital from also providing a plain language description in the additional notes data elements in the MRF.

We disagree with commenters that our proposal is arbitrary and capricious. We are asking hospitals to provide within the MRF, all standard charge information that they have in their systems and contracts to support the public to be able to derive the dollar amount. We are revising the attestation statement to retain the phase “to the best of its knowledge and belief” to acknowledge that there may be varied interpretations of contract calculations that could lead to variation in price, that the hospital may not know at the time of MRF development every factor that may impact the price or the payer may not have disclosed all factors to the hospital, and that for many hospital services the price is determined after services are performed at the episode of care level, not at the line item level, which would hinder an MRF user from being able to derive a price prior to services being performed.

Comment: A few commenters questioned that the attestation in its current form risks exposing hospitals to undue risk under the False Claims Act (FCA) and stated that CMS' existing assurances that this requirement falls outside the scope of the FCA are insufficient to allay hospital and health system concerns. Although commenters appreciated CMS' perspective, as set forth in the proposed rule, that noncompliance with this new requirement would not implicate the FCA, commenters expressed concern that there is no evidence that the Department of Justice, regulators, or judges would agree. These commenters stated that, to ensure that these new attestation requirements do not generate FCA challenges, CMS must articulate why the rule would not give rise to FCA liability. Commenters suggested that the Department of Justice could co-issue a policy stating that it would move to dismiss all FCA cases based on this attestation requirement, and stated that, short of that, no signatory could be confident that an attestation would not be used against them, or their institution.

Response: We appreciate commenters' concerns but forcefully reiterate, as stated in the CY 2024 OPPS/ASC final rule with comment period (88 FR 82086, 82116), that this final rule with comment period falls outside the scope of the FCA.

In tandem with that, and as discussed in response to a comment summary earlier in this section, we have elected not to finalize the removal of the statement, “to the best of the hospital's knowledge and belief” from the attestation statement, to reflect that we do not view the attestation as an absolute guarantee of perfection, but instead, as a reassurance to CMS and MRF users that to the best of the hospital's knowledge and belief, it has included all applicable standard charge information in accordance with the requirements of Sec. 180.50, and the information encoded is true, accurate, and complete as of the date in the file. We believe that the inclusion of this statement should help allay commenters' concerns. We further note that while we have strengthened the attestation statement to require the hospital to attest that it has provided “all necessary information available to the hospital for the public to be able to derive the dollar amount” in cases where the payer-specific negotiated charges cannot be expressed as a dollar amount in the MRF or are not knowable in advance, we emphasize that this attestation requires the hospital to provide information that is “available”

to the hospital, which does not require hospitals to provide any information to which they do not have access.

Comment: Several commenters expressed concern that the requirement to include “all necessary information” for the public to derive the dollar amount for cells that use algorithms or formulas could expose hospitals to significant legal challenges because many pricing algorithms rely on proprietary groupers or logic developed and owned by payers or third-party vendors. Commenters stated that such methodologies or reimbursement structures are often protected under intellectual property agreements or confidentiality clauses in hospital contracts, and requiring hospitals to encode such logic in the MRF could expose them to contractual breaches or legal liability. Commenters further noted that encoding such information may not even be technically possible because some components are completely and wholly managed by the payer and/or third-party vendor. A few commenters generally expressed concern that under the proposed attestation language, hospitals would be required to include privately negotiated contract terms in their MRFs or contract data that is contractually protected. A few commenters stated that the original price transparency rule struck an appropriate balance by requiring disclosure of prices without mandating hospitals to publish the full text of their contracts or all the underlying formula mechanics. Commenters asserted that the proposed attestation requirement goes well beyond the intent of helping patients understand prices, veering instead into revealing trade secrets that do not meaningfully help a patient estimate their out-of- pocket cost. Commenters believed that the attestation's purpose should simply be to ensure hospitals are making a good-faith, comprehensive effort to post the required standard charge information

Response: Consistent with the Executive Order 14221, Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information, the requirements we are finalizing advance our longstanding goals of equipping health care consumers with more meaningful and actionable price information to make well-informed healthcare decisions and supporting a more competitive, innovative, affordable, and higher quality healthcare system. This extends to ensuring that the MRF contains all accurate and complete information that the MRF users may need in order to be able to derive a payer-specific negotiated charge, including those formulas and algorithms used to derive the payer-specific negotiated charge.

Hospitals have had 4 years to demonstrate their good faith effort to make public the required standard charge information, but in that time we have assessed hospitals 2,531 warning notices, required 1,419 plans of corrective action, and imposed 27 CMPs (totaling 3,977 enforcement actions, and in the proposed rule we noted that only 7,416 hospitals meet our regulatory hospital definition (90 FR 33835)). Meanwhile, many MRF users are still confused by the dearth of data in the MRF files and whether the hospitals have indeed disclosed all the items and services they offer and the corresponding required standard charges for those items and services.\470\ As we stated earlier in this rule and in prior rules, we believe MRF users (for example innovators, researchers, employers) will use this data to analyze and draw more meaningful comparisons of hospital standard charge information, identify outliers and encourage market competition, support more effective contract negotiations, and develop downstream tools to support patient price comparisons.

\470\ Data is inclusive of compliance actions from January 1, 2021, through August 31, 2025.

We do not discount commenters assertions that various confidentiality provisions may generally protect the terms of various contracts or products that intersect with price transparency, but reiterate the point we articulated in the CY 2020 HPT Final Rule (84 FR 65544) that such contracts typically include exceptions where Federal law requires such a disclosure. Our view, which we explained in the CY 2020 HPT Final Rule (84 FR 65544), is that the Defend Trade Secrets Act of 2016 (18 U.S.C. 1905), which we do not believe is applicable here, applies only to trade secrets that are “misappropriated,” which is defined by reference to, among other things, “improper means,” where there was a “duty to maintain the secrecy,” or “accident or mistake.” We do not believe any of the meanings of the term “misappropriation” under the Defend Trade Secrets Act apply to a circumstance where an agency rule requires disclosure of certain information. Making these charges public enables, among others, health care consumers to be better informed about the cost of care, enabling them to compare options and make informed decisions. In turn, this transparency fosters competition among providers, advancing our broader goal of lowering overall healthcare costs.

We also disagree with commenters asserting there are many pricing algorithms that rely on proprietary groupers or logic developed and owned by payers or third-party vendors for which they cannot provide information used to determine what the hospital will be reimbursed. While there may be components of such negotiated fee schedules that may depend on proprietary data or algorithms (such as proprietary groupers), this would not preclude a hospital from being able to provide all the information available to it to reflect the negotiated amount for that item or service, either as a payer-specific negotiated charge dollar amount or the formula or algorithm and the historically received allowed amounts. To support hospital implementation efforts, we will provide examples of how to encode specific scenarios in the CMS Hospital Price Transparency--Data Dictionary.

Comment: Several commenters were concerned that implementing the proposed attestation statement would overwhelm the file with conditional logic and supporting documentation that cannot conform to the file schema and would undermine the goal of machine-readability and comparability.

Response: We thank commenters for these comments. In addition to the examples we have provided, we will provide additional examples on how to encode data and information required in the attestation statement on the CMS Hospital Price Transparency--Data Dictionary GitHub Repository website.

Comment: A few commenters supported our proposal to encode within the MRF the name of the hospital chief executive officer, president, or other senior official designated to oversee the encoding of true accurate and complete data. These commenters stated their belief that this requirement appropriately enhances executive accountability and reinforces the importance of leadership engagement in ensuring transparent and reliable pricing information for the public.

Response: We thank commenters for their support of this proposal. As discussed in the proposed rule (90 FR 33799), we believe the inclusion of the name of a hospital senior official will provide CMS actionable and enforceable certainty, and MRF users additional assurance, including in situations where the hospital's payer-specific negotiated charge is based on a contractual algorithm, percentage, or formula by which a hospital genuinely cannot specify a dollar amount, that the data were reviewed and verified by the

hospital's leadership, and would expedite our ability to quickly identify an individual at the hospital to obtain, where necessary, further clarity regarding the MRF data. For the reasons stated previously, we believe inclusion of the name of the CEO, president, or senior hospital official designated to oversee the encoding of true, accurate, and complete data in the MRF is reasonable and appropriate to achieve our stated goals.

Comment: Many commenters disagreed with the proposal to require hospitals to encode the name of the CEO, president, or senior hospital official designated to oversee the encoding of true, accurate, and complete data in the MRF because it would be unnecessarily burdensome to the hospital executive, hinder their ability to fulfill their primary role of focusing on strategic vision and overall governance, or introduce delays without improving accuracy. Several commenters stated that it would be unreasonable to expect the executive to personally validate potentially hundreds of thousands or millions of data points, noting that such executives are likely to rely on staff review and confirmation of the data. Instead, commenters stated that CMS should trust the good faith of others within the hospital who are far closer to the information and can verify its accuracy far more directly and easily than someone higher on the organizational chart with broader responsibility. Commenters also noted that compiling and interpreting standard charge information is extraordinarily complex, requiring interpretation of numerous assumptions and formulas, changing regulatory requirements, and intricate contract terms, and expressed concern that there is no recognition that given the vastness of the data required, an error could be overlooked despite all efforts to prevent it. One commenter further noted that there are entire software solutions designed to understand payment rates. Several commenters stated that the attestation requirement places a hospital executive in the untenable position of having to certify information beyond their practical control or granular knowledge, potentially exposing them to legal risks, with one commenter specifically recommending that the attestation be provided by the compliance officer or revenue cycle leader directly involved in the MRF development.

A few commenters expressed concern that CMS offered no support for requiring hospitals to encode the name of the CEO, president, or senior official and stated that “conclusory reasoning” cannot withstand scrutiny. Commenters noted that the agency did not consider the significant administrative burdens on the named attester, nor did it provide any support for why other employees within a hospital would not provide “meaningful, accurate information.” These commenters stated that absent actual support for this proposal, the agency should not add to the burdens of hospital leaders.

A few commenters generally stated that the current affirmation is sufficient and that it is unnecessary to require hospitals to make an attestation and encode the name of the hospital CEO, president, or senior official. One commenter asked if the hospital executive name encoded in the proposed attestation needed to match who the hospital designates as the CMS authorized and delegated official when under compliance review.

Response: We disagree with commenters and believe the reassurance to MRF users that the MRF contains data that is accurate and complete as of the date encoded in the MRF far outweighs any burden to the hospital executives whose names are encoded in the MRF. We believe the proposed requirement that hospitals encode in the MRF the name of a senior hospital official as the attester appropriately strengthens the attestation and the reassurances it provides to MRF users and CMS by providing accountability at a senior management level for the accuracy and completeness of the data. While we recognize that the senior hospital executive may not be directly involved in MRF development, we expect the named attester, as part of their role in the overall governance of the hospital, would, as necessary, be able to consult with the appropriate personnel more directly involved in MRF development, such as a compliance officer or revenue cycle leader as suggested by a commenter, in order to obtain the necessary information to make the required attestation. As such, we do not believe the proposed attestation requirement will hinder the executive's primary role within the hospital, create delays in the MRF development process, or place the attester in a position of having to attest to information of which they have no knowledge. Other CMS programs require a senior hospital executive to attest to complex financial information; for example, CMS requires a Chief Financial Officer or hospital administrator to read, prepare, and sign CMS-2552-10 (Hospital and Hospital Health Care Complex Cost Report) after the cost report has been completed.\471\

\471\ https://www.cms.gov/regulations-and-guidancelegislationpaperworkreductionactof1995pra-listing/cms-2552-10.

We have provided some flexibility on the title of the senior hospital executive who would attest to the file's accuracy and completeness, and indicated in the proposed rule (90 FR 33799) that we would expect the senior hospital official who is named as the attester in the file would be the same individual who would submit to CMS, if requested as part of CMS' monitoring oversight, a certification of the accuracy and completeness of the MRF data under Sec. 180.70(a)(2)(iv). We recognize that we did not include in section XXIII. (Collection of Information Requirements) the applicable burden level for CEO review of the MRF and have added an additional 2 hours to both the one time and annual burden estimates.

Comment: A few commenters stated that requiring the proposed attester name data element would raise concern that any unintentional errors in the MRFs may be punitively attached to the name of a single person, including exposing hospital executives to excessive liability or public criticism over unintentional, technical variances. The commenters stated that since the MRFs are published on the public- facing websites of hospitals, they urged CMS to not finalize the proposed “attester name” data element. One commenter believed that this would pose unnecessary privacy and security concerns and would not, in any way, advance the utility of price transparency regulations. One commenter further stated that the proposal raised potential safety and security concerns for the hospital executive named on the MRF, noting that requiring a named individual to publicly affirm the accuracy and completeness of complex pricing data could inadvertently expose that person to unintended harm. Given this, commenters urged CMS to retain the existing language requiring a good faith affirmation that the data is true, accurate, and complete.

Response: We acknowledge commenters' apprehension that the addition of the hospital senior official name could create privacy or security concerns; however, senior officials' names are already disclosed in multiple other public documents, including on the hospital's own website and in press releases, on state hospital licensure websites and, for Medicare-certified hospitals, information on hospital administration, including senior

officials' names, is publicly disclosed on the CMS website in the “Hospital All Owners” dataset and well as in the National Plan & Provider Enumeration System (NPPES) NPI Registry. Further, we believe that, by virtue of our modification that includes retaining the statement “to the best of its knowledge and belief,” hospitals and senior hospital officials would be less likely to receive public criticism over unintentional, technical variances.

Comment: A few commenters noted that requiring attestation by a CEO or other senior official would be duplicative of other existing hospital price transparency regulatory requirements. One commenter noted that hospitals are currently required to submit a certification of MRF data accuracy and completeness from an authorized hospital official on CMS' request; and to include a point of contact in their .txt files. This commenter believed these existing processes are fully appropriate and adequate, particularly given the complex nature of this data, noting that having a centralized hospital liaison who can either directly answer an MRF data question and/or refer to the appropriate individual, as applicable, would ensure efficiency and clarity. This commenter further noted that CMS already has the authority to request a certification. One commenter urged CMS to omit the proposed change to add another, more senior contact person in the MRF and keep the process as is. Another commenter stated that if CMS requires encoding the CEO's name within the MRF, it recommended direct communication with the individual named in the .txt file first to address any concerns, and if no response is provided, communication be directed to the CEO and the individual, recommending that CMS prioritize the use of email communication over postal mail to prevent delays. Another commenter stated that seeking a certification from a hospital official would be duplicative of the initial attestation without offering additional clarity on whether the file is truly compliant in the eyes of the regulators.

Response: We disagree with commenters that this information is duplicative as the MRF .txt file contact name is a person who can answer technical questions from entities such as innovators and researchers about the file structure and data encoded within it, but not attest to accuracy and completeness of the data. We further disagree that the proposed requirements are duplicative of the certification requirement at Sec. 180.70(a)(2)(iv) as our stated goal for adding the attester name was to provide further reassurance to the public of the accuracy and completeness of the MRF, while the certification requirement is provided directly and only to CMS under the compliance process.

Comment: We received one comment in response to our alternative that the attestation reside in a separate document on the hospital's website. That commenter responded that the attestation statement and attestor name should reside within the MRF.

Response: We appreciate the comment and agree that the attestation confirmation and attestor name should reside in the MRF.

Comment: We received comments on a few additional alternatives for this proposal. One commenter suggested the addition of a signature within the file, and another commenter suggested we require the senior hospital official to specifically have one of the following titles: the hospital's Chief Executive Officer, Chief Financial Officer, Chief Revenue Officer, or their equivalents. One commenter suggested an alternative, that in order to provide all necessary information for the public to derive a dollar amount, the hospital should make public a separate formula sheet providing the complete underlying formula by which actual reimbursement would be determined, because algorithms, formulas, and percentages make the file no longer machine-readable.

Response: We decline to require a signature within the MRF file, given that the MRF required formats, JSON and CSV, do not permit the inclusion of electronic signature solutions. If a hospital is found noncompliant, CMS already has the authority under Sec. 180.70(a)(2)(iv)-(v) to require the authorized hospital official to submit to us a signed certification as to the accuracy and completeness of the standard charge information encoded within the MRF. We decline at this time to be more prescriptive regarding the title of the senior hospital official, as we stated in the proposed rule that we want this name to align to the authorized hospital official who would submit to us the aforementioned signed certification, but we may revisit this suggestion in future rulemaking. We also decline the suggestion to require hospitals to provide additional files outside of the MRF, and require that hospitals encode all relevant data within the MRF.

Final Action: After consideration of public comments, we are finalizing, effective January 1, 2026, our proposal to supplant the existing affirmation requirement with the proposed attestation statement at new Sec. 180.50(a)(3)(iii), with a modification to add the following phrase to the beginning of the attestation: “To the best of its knowledge and belief,”. In addition, we are finalizing, as proposed, new Sec. 180.50(a)(3)(iv) to require that, beginning January 1, 2026, the hospital must encode within the MRF the name of the hospital chief executive officer, president, or senior official designated to oversee the encoding of true, accurate and complete data as directed in Sec. 180.50(a)(3)(iii). We are also modifying proposed Sec. 180.50(a)(3)(i) and (ii) to clarify that these provisions apply beginning January 1, 2024 through December 31, 2025, such that these provisions will no longer be effective as of January 1, 2026. Finally, as discussed in section XIX.B.7. (Effective Dates), although these revisions to the attestation requirements will be effective January 1, 2026, we will delay enforcement of these revisions until April 1, 2026. 6. Requirement To Report Hospital National Provider Identifier (NPI) Information in the Machine Readable File

We proposed to revise Sec. 180.50(b)(2)(i)(A) to require hospitals, beginning January 1, 2026, to report a unique identifier, specifically their NPI(s), in their MRFs. As we explained in the proposed rule, we believe that having hospitals add their NPI(s) to the MRF would improve the comparability of HPT and other healthcare data, including health plan transparency data from the TiC MRFs. Below, we explain the details of this proposal, including how we proposed that hospitals would encode their NPI(s) in their MRFs.

An NPI is a unique 10-digit number used to identify healthcare providers and organizations, including hospitals.\472\ All healthcare providers that are HIPAA-covered entities must obtain an NPI.\473\ Health care providers who are individuals are assigned a Type 1 NPI and healthcare providers that are organizations are assigned a Type 2 NPI (69 FR 3440). Type 2 NPIs are also known as organizational NPIs. “Subparts” of organizations--which are components of the same organization that may be separately licensed or identified \474\--may also obtain a Type 2 NPI (69 FR 3441) if they conduct HIPAA

standard transactions separately \475\ from the main organization (45 CFR 162.410(a)(1)). Entities and individuals maintain NPIs unless they are deactivated upon request, death, or dissolution (45 CFR 162.408(c)), and NPIs do not change if provider name, EIN, or state licensure changes (69 FR 3441). There are several internet-based NPI lookup tools available online, including CMS' NPPES NPI registry.\476\ NPIs are commonly used in other CMS systems for financial transactions, and for other healthcare data sets, including claims, utilization, and quality data sets.

\472\ https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand.

\473\ Ibid.

\474\ Guidance on NPI Enumeration; 45 CFR 162.412(b). https://www.cms.gov/files/document/guidance-national-provider-identifier-npi-enumeration-pdf.pdf.

\475\ https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand/downloads/medsubparts01252006.pdf.

\476\ CMS's NPPES registry is available online at the following website address: https://npiregistry.cms.hhs.gov/.

Under the current HPT regulations at Sec. 180.50, hospitals must provide identifying information, including hospital name, address, license number, and the Employer Identification Number (EIN) either in the MRF file name or the file itself. We stated in the proposed rule that while these elements help to identify the hospital, interested parties have told us that they are inadequate to facilitate comparing hospital MRF data with other datasets that include hospital-related information and that a standard identifier would bolster these efforts. In particular, commenters stated that the lack of a standard identifier in the MRF hinders efforts to compare standard charge information across files and limits opportunities to automate the comparison and analysis of HPT and TiC MRF data. Innovators, researchers, and other MRF users have stressed to us the importance of including standard identifiers to streamline data and reduce the complexity of analyzing numerous and different disclosures. The currently required hospital license number is useful to help crosswalk the name of the hospital with the state license number, but because it differs from the identifier required in the TiC files, innovators and researchers have noted that they find it difficult to compare across files. We also note that EINs, while required as part of the naming convention for the hospital MRF and included in the TiC MRF, are generally not included in CMS datasets or other public financial and claims datasets. Therefore, we stated in the proposed rule that we believe it is important to require hospitals to report a standard identifier, specifically the NPI, which is used in the TiC MRFs and in CMS systems such as the Provider Enrollment, Chain, and Ownership System (PECOS), to maximize comparability across data and files.

Moreover, Executive Order 14221 directs HHS to ensure that pricing information is standardized and easily comparable across hospitals and health plans.\477\ We stated in the proposed rule that, to this end, we believe it is important to align the HPT MRF and the TiC identifier data element. Under the TiC final rule (85 FR 72158), and as described in the TiC GitHub schemas for the “In-Network File,” “Out-Of-Network Allowed Amount File,” and the optional “Provider Reference File,” most group health plans and health insurance issuers must post pricing information, and such pricing information must be associated with a provider's NPI to ensure that consumers have reliable data and can make informed healthcare purchasing decisions.\478\ We explained in the proposed rule that we believe aligning the NPI across the HPT and TiC MRFs would support improved cross-comparison among hospital data and health plan data, providing users of both MRFs further context about hospital standard charges.

\477\ https://www.whitehouse.gov/presidential-actions/2025/02/making-america-healthy-again-by-empowering-patients-with-clear-accurate-and-actionable-healthcare-pricing-information/.

\478\ https://github.com/CMSgov/price-transparency-guide.

We specifically proposed to require, beginning January 1, 2026, that hospitals report, in a newly created general data element in the MRF, any Type 2 NPI(s) that has a primary taxonomy code starting with `28' (indicating hospital) or `27' (indicating hospital unit) and that is active as of the date of the most recent update to the standard charge information. We proposed to limit the Type 2 NPI(s) that hospitals would report to only those that meet this taxonomy criteria, because while hospitals may have more NPIs beyond these criteria for other departments or units, these taxonomy codes limit the number of NPIs to only those indicating hospital or hospital unit. In the case that hospitals have more than one NPI that meet the proposed criteria above, we proposed that hospitals would be required to report in the general data element all active Type 2 NPIs meeting the criteria. We stated that we would include additional technical instructions in the CMS data dictionary and CSV template and JSON schema in the Hospital Price Transparency--Data Dictionary GitHub Repository available at https://github.com/CMSgov/hospital-price-transparency. We sought comment on our proposal and any additional taxonomy codes that would be necessary or helpful to consider.

We considered in the proposed rule, as an alternative, that should a hospital have multiple Type 2 NPIs, it would be required to report only one NPI. We stated that with this alternative, MRF users could crosswalk the NPI to identify additional NPIs. A review of the publicly available January 2025 data from PECOS, the online Medicare enrollment system, found that only approximately 10 percent of hospital enrollment applications reported multiple NPIs.\479\ This data was cross-walked with NPPES data to find the provider taxonomy code (a 10-digit code that designates classification or specialization), whether the NPI was still active in the system, and whether an NPI was classified as an organization subpart. The majority of reported NPIs for applications with multiple NPIs were active. Some applications reported as many as 27 NPIs with a hospital or hospital unit taxonomy. However, the median number of NPIs with a hospital or hospital unit taxonomy was two and the average number of NPIs with a hospital or hospital unit taxonomy was 1.9. For this reason, we stated in the proposed rule that we believe requiring hospitals to include NPIs that meet our proposed criteria would not pose a significant burden or, for most hospitals, significantly increase the amount of data stored in the MRFs.

\479\ CMS Hospital Enrollments and Hospital Additional NPIs datasets https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/hospital-enrollments.

We also considered requiring that hospitals include other identifiers in their MRF, such as the CMS Certification Number (CCN). CCNs are assigned by CMS and used to identify healthcare facilities participating in the Medicare Part A and Medicaid programs.480 481 Hospitals primarily have assigned CCNs as entities, but CCNs can also be used to identify specific hospital locations or units, especially when those units operate under the same organizational umbrella but at different sites. CCNs do not change when hospital ownership changes, but hospital mergers, acquisitions, and consolidations can result in CCN changes. We elected not to propose to require that hospitals encode CCNs because CCNs are limited to Medicare- or Medicaid-participating hospitals, while the HPT regulations apply to all hospitals in the United States (with exceptions listed at Sec. 180.30(b)), and, also, the inclusion of

CCNs would not align with the TiC provider identifier requirements.

\480\ https://www.cms.gov/files/document/provider-enrollment-certification-roadmap.pdf.

\481\ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c10.pdf.

We sought comment on our proposal, as well as any additional, or alternative, taxonomy codes that commenters believe would be necessary or helpful to consider. We also sought comment on other standard identifiers that may be useful in providing needed context for and streamlining the alignment of price transparency data.

We received public comments on this proposal. The following is a summary of the comments we received and our responses.

Comment: Many commenters supported our proposal to revise Sec. 180.50(b)(2)(i)(A) to require hospitals to report a unique identifier, specifically their Type 2 NPI(s), in their MRFs. Supportive commenters stated that the Type 2 NPI is a valuable identifier for linking to claims data and provider directories, and the inclusion of this information in the MRF would enhance interoperability across datasets, including TiC files. Further, commenters indicated that adding NPI information to the MRFs would allow payers, employers, and researchers to match hospital pricing information more reliably with utilization and outcomes data to identify variation in negotiated rates, analyze payment trends, and develop tools that empower consumers to make informed healthcare purchasing decisions.

Response: We thank commenters for their support of this proposal.

Comment: Several commenters did not support the proposal to include the NPI in the MRF. A few commenters believed it would increase burden to hospitals. One commenter questioned our analysis that only 10 percent of hospitals nationwide would report multiple NPIs. One commenter opposed the inclusion of the NPI as it could add technical and operational complexity when combined with other CMS requirements. This commenter argued that including the NPI with detailed pricing data could expose specific contracting arrangements.

Response: We thank commenters for their comments on this subject. We disagree with commenters that this proposal would add significant burden to hospitals or that it would add complexity to the files. We reiterate that the Type 2 NPI would be listed as a general data element (in CSV) or data attribute (in JSON) in the MRFs that would only need to be included once in the file, not repeated for each item and service. This would be similar to the hospital name, location, and address data that innovators and researchers use to correctly attribute files to locations. Since the requirement is confined to one data element/attribute where the hospital is being asked to list all their NPIs only once, we do not anticipate a significant increase in file size. As we indicated in the proposed rule, our review of the publicly available January 2025 data from PECOS, the online Medicare enrollment system, found that only approximately 10 percent of hospital enrollment applications reported multiple NPIs registered as hospital or hospital units.\482\ This is validated by an Office of the Assistant Secretary for Planning and Evaluation (ASPE) report that found that the “vast majority” of hospitals only have one NPI and a “very small” number of hospitals have multiple NPIs.\483\ We anticipate that MRF users have the necessary sophistication and tools to navigate multiple NPIs and would appreciate the additional information. Furthermore, because the TiC files already include this information, we do not believe it exposes sensitive contracting information, but, rather, allows alignment and cross-comparison with other data sets.

\482\ CMS Hospital Enrollments and Hospital Additional NPIs datasets https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/hospital-enrollments.

\483\ Welch WP, Xu L, De Lew N, et al. Ownership of Hospitals: An Analysis of Newly-Released Federal Data & A Method for Assessing Common Owners: Data Point [internet]. Washington (DC): Office of the Assistant Secretary for Planning and Evaluation (ASPE); 2023 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK616123/.

Comment: A few commenters opposed the proposal because, they stated, insurers are not required to report NPIs in their TiC files, creating an uneven playing field. Another commenter expressed that the requirement to include Type 2 NPIs in the MRF would not make it possible to compare the information with TiC files, stating that TiC requires attributes that specifically define the payer network, plan, and item/service billing class.

Response: While insurers do not have NPIs, we disagree with commenters that insurers are not required to report NPIs in their TiC files, as they do report pricing information that must be associated with a provider's NPI. As we stated in the proposed rule, we proposed the NPI requirement to align more closely with the TiC requirements. Under the TiC final rule (85 FR 72158), and as described in the TiC GitHub schemas for the “In-Network File,” “Out-Of-Network Allowed Amount File,” and the optional “Provider Reference File,” most group health plans and health insurance issuers must post pricing information, and such pricing information must be associated with a provider's NPI to ensure that consumers have reliable data and can make informed healthcare purchasing decisions.\484\ We also disagree that the inclusion of the NPI will not improve comparability with the TiC files. While most group health plans and health insurance issuers do include additional data such as billing class, plan market type, and payer network, we believe the inclusion of the NPI will allow for a direct crosswalk between the hospital MRFs and the TiC MRFs. Prior to the inclusion of this data element, innovators and researchers would have to match files by hospital name, EIN, or hospital address. Because hospital name and address are not standardized, there may be variances between hospital and TiC MRFs. EINs may be used across health systems and may not be distinguishable between hospitals within the same health system. The NPI is a standard, unique, 10-digit identifier that hospitals have readily available for inclusion in their MRFs. Furthermore, we believe that some commenters may not have understood our proposal to require hospitals to enter their organizational taxonomy code(s), which begin with `28' or '27.' We are clarifying that our proposal was for hospitals to encode the NPI associated with a taxonomy code reflecting either a hospital or a hospital unit, not that the hospitals should enter the actual taxonomy code.

\484\ https://github.com/CMSgov/price-transparency-guide.

Comment: Several commenters suggested alternatives to our proposal for consideration. One commenter recommended that CMS require both the NPI and the CCN in the file to strengthen the link between hospital pricing data and other CMS datasets. One commenter recommended that CMS consider replacing the EIN in the file naming convention with the CCN. A few commenters recommended that CMS limit the requirement to a single Type 2 NPI that is associated with a primary taxonomy code starting with `28' but not require Type 2 NPIs beginning with a primary taxonomy code `27,' which represent hospital units, to reduce burden and confusion. One commenter suggested that hospitals include the TIN or EIN that is applicable for each negotiated rate. One commenter suggested that we require all NPIs associated with the hospital, beyond the NPIs associated with the taxonomy codes starting with `28' or `27.'

Response: We thank commenters for their suggestions and alternatives. We decline to include the CCNs in the files as CCNs are limited to Medicare- or

Medicaid-participating hospitals, while the HPT regulations apply to all hospitals in the United States (with exceptions listed at Sec. 180.30(b)). Additionally, we note that the inclusion of CCNs would not align with the TiC provider identifier requirements.

As we stated, the vast majority of hospitals have only one Type 2 NPI, and therefore we do not believe it would be overly burdensome to require hospitals to encode all Type 2 NPIs that have a primary taxonomy code starting with `28' or `27.' Furthermore, a review of the publicly available January 2025 data from PECOS, indicates that not all hospitals, such as psychiatric hospitals, have a Type 2 NPI with a primary taxonomy code starting with `28.' \485\ Therefore, requiring both strikes a balance ensuring that all hospitals subject to the HPT requirements will have an NPI listed in their MRF.

\485\ CMS Hospital Enrollments and Hospital Additional NPIs datasets https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/hospital-enrollments.

We do not believe it is necessary for hospitals to include all of their NPIs or include the NPI with each item and service. Innovators and researchers should have the ability to crosswalk to additional NPIs, if necessary, once they have a Type 2 NPI that is associated with primary taxonomy code starting with `28' or `27.' We also decline to include the EIN/TIN for each item and service. We do not believe this is necessary, as it will continue to be required in the file name and as it is applicable to the hospital, it would be applicable to all items and services.

We clarify that this requirement will require hospitals to report their Type 2 NPIs that are associated with a primary taxonomy code starting with `28' or `27.' As we described above, NPIs are unique 10- digit numbers used to identify healthcare providers and organizations, including hospitals. They are associated with taxonomy codes that identify a healthcare provider's specialty and type. Primary taxonomy codes that begin `28' represent hospitals. Primary taxonomy codes that begin with `27' represent hospital units. When applying for a NPI from the NPPES, a healthcare provider must select the Healthcare Provider Taxonomy Code or code description that the health care provider determines most closely describes the healthcare provider's type/ classification/specialization, and report that code or code description in the NPI application.\486\ Readers can reference the Medicare Provider and Supplier Taxonomy Crosswalk to familiarize themselves with the descriptions for each provider taxonomy code.\487\ Hospitals are only required to report their Type 2 NPIs that meet the criteria specified at Sec. 180.50(b)(2)(i)(A), not the taxonomy codes.

\486\ https://data.cms.gov/resources/medicare-provider-and-supplier-taxonomy-crosswalk-methodology.

\487\ https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/medicare-provider-and-supplier-taxonomy-crosswalk/data.

Final action: After consideration of public comments, we are finalizing, as proposed, the requirement that, beginning January 1, 2026, hospitals must report, in a newly created general data element in the MRF, any Type 2 NPI(s) that are associated with a primary taxonomy code starting with `28' (indicating hospital) or `27' (indicating hospital unit) and that is active as of the date of the most recent update to the standard charge information. As noted in the “Effective Dates” section below, while this requirement will become effective January 1, 2026, we will delay enforcement to April 1, 2026. 7. Effective Dates

In the CY 2026 OPPS/ASC proposed rule, we proposed several revisions to Sec. 180.50, that would be effective January 1, 2026, including removing the requirement for hospitals to disclose the estimated allowed amount, and, instead, disclose the median, and 10th and 90th percentile, allowed amounts, and the count of allowed amounts; requiring an attestation that the hospital has included all applicable standard charge information in the MRF and that the information encoded is true, accurate, and complete as of the date in the file; requiring the name of the hospital chief executive officer, president, or senior official overseeing the encoding of the data; and a requirement that hospitals must encode their Type 2 (organizational) NPIs. We also proposed at Sec. 180.90, beginning January 1, 2026, to reduce the amount of a CMP by 35 percent, under certain conditions, when a hospital waives its right to an ALJ hearing.

Comment: We received many comments related to the effective date of the proposed requirements at Sec. 180.50, with nearly all such commenters asserting that our proposed timeline was aggressive and that it would be unreasonable to require hospitals to update the data elements and implement the changes by January 1, 2026. Many commenters recommended alternative effective dates, ranging from 60 days to 2 years beyond our proposed effective date of January 1, 2026, that they considered more reasonable. Many commenters indicated that hospitals would need additional time to review new guidance, develop plans for updating the files, coordinate with vendors, encode the data, validate for accuracy, and refresh and post the files. A few commenters expressed concern that a January 1, 2026 implementation date would disrupt hospitals that are then updating their files in anticipation of annual updates. Several commenters expressed concern that hospitals only recently implemented the required CMS standardized templates and other requirements as of January 1, 2025, and would like more time before incorporating additional changes. A few commenters requested that we delay enforcement of the proposed requirements, rather than delay the implementation date.

Response: We believe that hospitals should adopt the new and updated data elements as soon as possible to improve public use of hospital standard charge information. However, in light of the comments, we understand that hospitals may require additional time to develop and encode the additional required information, particularly the new data requirements associated with the median, 10th percentile, and 90th percentile allowed amounts, and the count of allowed amounts. Therefore, while we are finalizing revisions to Sec. 180.50 effective beginning January 1, 2026, we will delay enforcement of those specific new requirements at Sec. 180.50 until April 1, 2026.

Final action: After consideration of public comments, we are finalizing that the effective date of the revisions at Sec. 180.50, including removal of the estimated allowed amount, disclosure of the median, and 10th and 90th percentile, allowed amounts and the count of allowed amounts, the attestation requirement, and the NPIs, will be January 1, 2026. However, we will delay enforcement of these finalized revisions until April 1, 2026. This 3-month enforcement delay will apply solely to enforcement actions based on the new requirements at revised Sec. 180.50 and in no way will affect already-initiated compliance actions or actions for noncompliance with other requirements under part 180 as they are currently being implemented. We believe this 3-month enforcement delay will provide hospitals with sufficient time to update their systems, and review, validate, and post their files.