Form CMS-10572 QHP Issuer Data Collection - Appendix A2

OMB Control Number: 0938-1310 Expiration Date: XX/XX/20XX

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Appendix A2. Transparency in Coverage Reporting by Qualified Health Plan Issuers - Plan Year 2027-2028

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General Information
Was this Issuer on the Exchange in 2025?*
SADP Only?*
Issuer HIOS ID*
Issuer Level Data
Number of In-Network Issuer Level Non-Behavioral Health Claims with Date(s) of Service (DOS) in 2025 That Were Also Received in Calendar Year 2025*
Number of In-Network Issuer Level Non-Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of In-Network Issuer Level Non-Behavioral Health Claim Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Out-of-Network Issuer Level Non-Behavioral Health Claims with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Out-of-Network Issuer Level Non-Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of Out-of-Network Issuer Level Non-Behavioral Health Claim Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of In-Network Issuer Level Behavioral Health Claims with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of In-Network Issuer Level Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of In-Network Issuer Level Behavioral Health Claims Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Out-of-Network Issuer Level Behavioral Health Claims with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Out-of-Network Issuer Level Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of Out-of-Network Issuer Level Behavioral Health Claims Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Issuer Level Internal Post-Service Claims Appeals Filed in Calendar Year 2025*
Number of Issuer Level Internal Post-Service Claims Appeals Overturned from Calendar Year 2025*
Number of Issuer Level External Post-Service Appeals Filed in Calendar Year 2025*
Number of Issuer Level External Post-Service Appeals Overturned from Calendar Year 2025*
Number of Issuer Level Pre-Service Benefit Requests Received in Calendar Year 2025*
Number of Issuer Level Pre-Service Benefit Requests Denied in Calendar Year 2025*
Number of Issuer Level Internal Pre-Service Benefit Requests Appeals Filed in Calendar Year 2025*
Number of Issuer Level Internal Pre-Service Benefit Requests Appeals Overturned from Calendar Year 2025 *
Number of Issuer Level External Pre-Service Benefit Requests Appeals Filed in Calendar Year 2025*
Number of Issuer Level External Pre-Service Benefit Requests Appeals Overturned from Calendar Year 2025 *
Notes:
Please enter any comments/notes here.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1310. This information collection is for the submission of data related to transparency in coverage by QHP issuers to HHS, the Exchange, and the state insurance commissioner, and also make the information available to the public in plain language. The time required to complete this information collection includes a one-time technical modification estimated to average 11 hours per response for QHP issuers and the time required to complete an annual submission of Transparency in Coverage data estimated to average 44 hours per response for QHP issuers, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. Pursuant to 45 CFR 156.220, QHP issuers are required to make this information available to consumers and CMS. CMS requires QHP issuers to update transparency in coverage data annually. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 and email Carolyn Sabini at Carolyn.Sabini@cms.hhs.gov, Attention: Information Collections Clearance Officer.

All fields with an asterisk ( * ) are required. To validate the template, press Validate button or Ctrl + Shift + I. To finalize the template, press Finalize button or Ctrl + Shift + F. All plan IDs submitted via Plans & Benefits Template(s) must be included in this template.

Centers for Medicare & Medicaid Services (CMS) Qualified Health Plan (QHP) Transparency in Coverage Reporting

Plan Year 2027

Plan Level Data
Plan ID*
Number of Plan Level In-Network Non-Behavioral Health Claims with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level In-Network Non-Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of Plan Level In-Network Non-Behavioral Health Claim Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level Out-of-Network Non-Behavioral Health Claims with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level Out-of-Network Non-Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of Plan Level Out-of-Network Non-Behavioral Health Claim Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level In-Network Behavioral Health Claims with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level In-Network Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of Plan Level In-Network Behavioral Health Claim Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level Out-of-Network Behavioral Health Claims with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level Out-of-Network Behavioral Health Claims with DOS in 2025 That Were Also Denied in Calendar Year 2025*
Number of Plan Level Out-of-Network Behavioral Health Claim Resubmissions with DOS in 2025 That Were Also Received in Calendar Year 2025*
Number of Plan Level Claims with DOS in 2025 That Were Denied Due to An Out-Of-Network Provider/Claims in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied Due to Enrollee Benefit Limit Reached in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied Due to Member Not Covered During All or Part of Date of Service in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied Due to Investigational, Experimental, or Cosmetic Procedure in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied Due to Referral or Prior Authorization Required in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied Due to Services Excluded or Not Covered in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied Due to Lack of Medical Necessity, Excluding Behavioral Health, in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied Due to Lack of Medical Necessity, Behavioral Health only, in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS In 2025 That Were Denied Due to Administrative Reasons in Calendar Year 2025*
Number of Plan Level Out-of-Network Claims with DOS in 2025 That Were Also Denied for "Other" Reasons in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied Due to Enrollee Benefit Limit Reached in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied Due to Member Not Covered During All or Part of Date of Service in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied Due to Investigational, Experimental, or Cosmetic Procedure in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied Due to Referral or Prior Authorization Required in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied Due to Services Excluded or Not Covered in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied Due to Lack of Medical Necessity, Excluding Behavioral Health, in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied Due to Lack of Medical Necessity, Behavioral Health only, in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS In 2025 That Were Denied Due to Administrative Reasons in Calendar Year 2025*
Number of Plan Level In-Network Claims with DOS in 2025 That Were Also Denied for "Other" Reasons in Calendar Year 2025*
Notes:
Please enter any comments/notes here.