Unpacking the specifics of the CY 2026 final rule

Between seasonal merriment and holiday festivities, the Turquoise Health team is dialed into an eggnog-fueled state of planning for 2026. A focal point for our hospital machine-readable file (MRF) team is the CY 2026 final rule that came out on November 21.

According to the Centers for Medicare and Medicaid Services (CMS), the updates to hospital price transparency (HPT) requirements within the final rule, which has a delayed enforcement date of 4/1/2026, are intended to “revise the HPT regulations to enhance clarity and standardization in hospital disclosure of standard charges.”

To that end, there are a few areas of focus within the revisions that hospitals and their MRF generation teams will need to address prior to the 4/1 enforcement date. Let’s walk through some of the relevant specifics below.

MRF Affirmation Statement

The attestation language builds on several previous HPT requirements designed to instill leadership-level accountability for hospitals as they post their rates and maintain their annual MRF refresh cadence. The required language is as follows:

“To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of § 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 MRF 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.”

In addition, CMS has finalized that “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.” Hospitals often have a specific team designated to manage their MRF builds or refreshes or they outsource the MRF generation process to a vendor. In either case, it is the responsibility of hospital senior leadership to ensure there are quality assurance measures taken to verify that what’s posted on the hospital’s website accurately reflects its CDM and standard charges.

National Provider Identifier (NPI) Reporting

Within the MRF, there’s a new field requirement tied to NPI reporting. Specifically:

“Hospitals will be required to report, in a newly created general data element in the MRF, any Type 2 NPI(s) that is associated with 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.”

According to the final rule, the rationale for this newly-added field is to more easily tie hospital MRF data to other healthcare data sets. Specifically, Transparency in Coverage (TiC) MRFs report pricing information associated with provider NPIs, and thus, if the NPI is included in hospital MRFs as well, the ideal outcome is that users would be able to consistently compare rates between the two files.

Percentile Allowed Amounts

According to CMS, the requirements here are written to “contextualize the standard charges, intended to improve the comparison of standard charge information and enable more meaningful disclosures to the public.”

The requirements terminate the Estimated Allowed amount field and create additional reporting focused on percentiles:

1. 10th Percentile Allowed Amount
2. Median Allowed Amount
3. 90th Percentile Allowed Amount
4. Count of each respective Percentile Allowed Amount
   

Each of the three Percentile Allowed Amount fields are defined as “values a hospital will encode when a payer-specific negotiated charge is based on a percentage or algorithm, to more accurately reflect the distribution of actual amounts that a hospital has received for an item or service.” This continued focus on allowed amount reporting is tied to ensuring the dollar amounts in the MRFs can effectively and accurately be utilized in creating upfront costs for patients. Though patients will not be accessing the data directly from the MRFs, the rate data can be utilized as the foundation for a cost estimator tool.

CMS also clarified how the Percentile Allowed Amounts are to be calculated: specifically by using “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.” The lookback period to calculate the allowed amount is also expanded to be the 12-15 months prior to posting the MRF.

Examples, Clarifications, and Future Education

The final rule also includes a number of nuanced examples and clarifications. For example:

“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.”

There are additional examples like the one above and CMS also committed to continuing to provide clarity and updated information both within the HPT GitHub and on their hospital Resources page.

The requirements within this final rule serve as a change in course from the May 22 requirements and render some of the work done over the summer obsolete; however, the processes surrounding using 835 data to calculate the Estimated Allowed Amount should pay dividends when teams transition to creating Percentile Allowed Amount reporting. And, given the final rule was public until late November, hospitals and their MRF generation teams were granted an additional 90 days to create files. We anticipate more support and guidance from CMS in the coming months to increase clarity.

Still have questions?

The Turquoise Health MRF creation team will be incorporating all the new requirements into our processes, and if you’d like to learn more, reach out here!