Why does a provider (e.g., an NPI, an EIN) that says they are in-network with a payer not show up in the data?
Several reasons could explain this, including:
- Their contract is new and the payer has not posted their rate information yet. We have seen up to a 3 month lag between a provider announcing they are in-network and their rates showing up in the transparency files.
- They do show up in the price-transparency data, but under a different identifier. Please review the following guide to finding providers in the data: https://serif-health.helpscoutdocs.com/article/23-guide-to-provider-search
- They do show up in the price-transparency data, but not for the desired code you searched for. Make sure you try the following to ensure a complete search:
- Search adjacent or similar codes to the ones you are interested in. For E&M visit codes, as an example, try the full range of 99202-5 and 99212-5 to see if you can pick up additional data points. Some resources on finding related revenue codes are here and here.
- For finding institutional fees, we recommend searching both the CPT / DRG procedure code and the associated revenue code. A resource for finding relevant revenue codes is linked here.
- They do show up in the price transparency data, but another filter is present blocking them from showing. When searching for a specific provider, our recommendation is to clear all filters related to: region, taxonomy, billing_class, is_billable, negotiation type, arrangement, place of service, and outliers. The only parameters present should be payer, codes, and provider.
- If you have exhausted all possibilities (e.g., searched a complete set of NPIs and EINs, searched a broad range of codes) for a given payer, it is likely the payer’s transparency data contains gaps. If you would like to issue a formal complaint to the CMS, their form is here.