CMS-10572 Data Elements - Appendix A1

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

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Centers for Medicare & Medicaid Services (CMS) Qualified Health Plan (QHP) Transparency in Coverage Reporting Plan Year 2026

General Information
Was this Issuer on the Exchange in 2024?*
SADP Only?*
Issuer HIOS ID*
Issuer Level Data
Number of Issuer Level In-Network Claims with Date(s) of Service (DOS) in 2023 That Were Also Received in Calendar Year 2024*
Number of Issuer Level In-Network Claims with DOS in 2023 That Were Also Denied in Calendar Year 2024*
Number of Issuer Level In-Network Claims with DOS in 2023 That Were Also Resubmitted in Calendar Year 2024*
Number of Issuer Level Out-of-Network Claims with DOS in 2023 That Were Also Received in Calendar Year 2024*
Number of Issuer Level Out-of-Network Claims with DOS in 2023 That Were Also Denied in Calendar Year 2024*
Number of Issuer Level Out-of-Network Claims with DOS in 2023 That Were Also Resubmitted in Calendar Year 2024*
Number of Issuer Level Internal Appeals Filed in Calendar Year 2024*
Number of Issuer Level Internal Appeals Overturned from Calendar Year 2024 Appeals*
Number of Issuer Level External Appeals Filed in Calendar Year 2024*
Number of Issuer Level External Appeals Overturned from Calendar Year 2024 Appeals*
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 2026

Plan Level Data

Plan ID*

Number of Plan Level In-Network Claims with Date(s) of Service (DOS) in 2024 That Were Also Received in Calendar Year 2024*

Number of Plan Level In-Network Claims with DOS in 2024 That Were Also Denied in Calendar Year 2024*

Number of Plan Level In-Network Claims with DOS in 2024 That Were Also Resubmitted in Calendar Year 2024*

Number of Plan Level Out-of- Network Claims with DOS in 2024 That Were Also Received in Calendar Year 2024*

Number of Plan Level Out-of- Network Claims with DOS in 2024 That Were Also Denied in Calendar Year 2024*

Number of Plan Level Out-of- Network Claims with DOS in 2024 That Were Also Resubmitted in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due to Prior Authorization or Referral Required in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due to an Out-Of- Network Provider/Claims in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due to Exclusion of a Service in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due to Lack of Medical Necessity, excluding Behavioral Health in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due to Lack of Medical Necessity, Behavioral Health only, in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due to Enrollee Benefit Limit Reached in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due to Member Not Covered During All or Part of Date of Service in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied Due To Investigational, Experimental, or Cosmetic Procedure in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Denied Due to Administrative Reasons in Calendar Year 2024*

Number of Plan Level Claims with DOS in 2024 That Were Also Denied for "Other" Reasons in Calendar Year 2024*

Notes: (Please enter any comments/notes here.)