Transparency in Coverage Solution

Solving Transparency in Coverage with TALON’s Core Assets And Expertise

Our founder and CEO, Mark Galvin, worked closely with the different cabinet level departments in the Administration, demonstrating TALON’s premier cost containment platform,  as well as offering his overall guidance.  Our current cost containment platform solution and architecture fits the two (2) major requirements like a glove!

1. Publicly Available Machine-Readable Files(updated monthly)

On January 1st, 2022, Employer-sponsored Group Health Plans and Health Insurance Issuers must provide the following three machine-readable files:

    • negotiated rates for all covered items and services between the plan or issuer and in-network providers;
    • historical payments to, and billed charges from, out-of-network providers; and
    • in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level.

2. Self Service Tool

Employer-sponsored Group Health Plans and Health Insurance Issuers must make available to participants, beneficiaries and enrollees (or their authorized representative) the following:

    • Personalized out-of-pocket cost information, and the underlying negotiated rates for all covered health care items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request.

Unlike the machine-readable files, the self-service tool may be introduced over two phases:

    • For all plans beginning on or after January 1, 2023 – Plans and issuers must make cost-sharing information available for 500 items and services identified by the Department for plan years (in the individual market for policy years)
    • For all plans beginning on or after January 1, 2024 – The same requirement imposed as of 1/1/23, but for ALL services, items, and prescription drugs

TALON’s Uniqueness

TALON is the expert in parsing complex non-standard data files and payer arrangements from numerous sources. Since its inception in 2014, it has been creating standard format file structures to expose the hidden prices for procedures and bundled services.

  1. TALON is uniquely qualified to parse the complex non-standard format files from the TPA’s multitude of carriers, and other value-added pricing arrangements required for the three machine readable files.
  2. Through proprietary machine-learning algorithms, TALON easily creates the standard GitHub compliant three machine-readable files as defined and required under the Transparency in Coverage rule.
  3. TALON leverages its unique ability to ingest and parse the data files to establish in and out of network negotiated rates for services, items and prescriptions to produce the required machine-readable files.
    • Ensures early compliance and ability to offer Safe Harbor for your employer groups
  4. TALON’s technologies enable access to a fully-compliant Self-Service Tool (MyMedicalShopper) creating a competitive advantage and market differentiation.

Early Compliance, Safe Harbor and the Gold Standard Self-Service Tool

Please contact us to learn all the details how we do it!

Talons Machine Learning System