Guidelines for ordering an mrf report

Step 1

Insurance reimbursement depends heavily on geographic region due to variances in cost of living as well as malpractice rates. The first step is to determine your regional competitors and crucially, find their NPI numbers. These can be easily looked up. If possible, a Type 2 NPI corresponding to the practice entity (as opposed to a Type 1 NPI corresponding to a practitioner) almost always yields more thorough results.

Step 2

Once a list of NPI’s has been established, you’ll need to consider which CPT’s are most relevant to your practice. A list of reference codes can be found here: https://www.aapc.com/codes/cpt-codes-range/

Please note that insurance companies are only legally required to publish reimbursement data if certain volume quotas a met. For more information about these quotas, please see the FAQ section at the bottom of this page.

Step 3

Despite the strict file format rules mandated by CMS, each insurance company’s MRF files are structured uniquely. This means that the code written to analyze the files is not transferrable between payers and must be rewritten to parse a new MRF (for reference, this code is ~1000 lines long). Currently, analysis of the following payers is available with more being constantly added. Please indicate which of these you would like. Individual reports are generated for each payer.

- Blue Cross Blue Shield of New Mexico

- Presbyterian Health Services

- United Health Services (New Mexico)

Step 4

Download the requisition form at the bottom of this page and fill out your NPI, CPT and payer requests. Please read through the disclaimer and understand what information is guaranteed, and what is not. Once you have filled out the requisition, it can be submitted as an attachment on the contact form of this website, or can be emailed to me directly at nmanzf35@gmail.com

Frequently Asked Questions

Is this legal?

Yes. The intention of the TiC law was to put pricing information into the hands of medical consumers, and the ability of providers to benefit has been a secondary result. Since the MRF files are available to the general public, reading and leveraging them as a tool during planned negotiation with insurance is not in violation of anti-trust laws. However, you are encouraged to seek your own legal advice.

Can you ensure the data is up to date?

The TiC law requires MRF files to be updated and re-published monthly. Your report will show not only the URL location of the MRF files on the web, but will also show when the MRF was published, down to the minute.

What information are payers required to disclose?

The TiC law only requires payers to disclose their negotiated rates (on a per NPI and per CPT basis) if a particular NPI/CPT pair has been billed more than 20 times per calendar month. In other words, if practice A bills twenty-five 99214’s in May but only nineteen 99213’s, rate information for the 99213 may or may not be available while the 99214 is guaranteed to be present. As these volume numbers change month to month, so too will the disclosures in the updated MRF’s.

How do I know if the information I request will be present?

The short answer, you don’t. Not until after they’ve been parsed anyways. That is why it is important to be discerning when selecting the NPI’s and CPT’s to request in your report. During the generation of the report, a record is kept of any CPT's that fail to return data across all requested NPI's. In the event that such CPT's are encountered, a discount of $150 per affected CPT will be applied.

What does the data generally show?