The OPPS final rule effective January 1, 2026 enhances hospital price transparency regulations, requiring hospitals to provide more comprehensive and accessible pricing information through machine-readable files. This initiative aims to empower patients and employers with meaningful price data, thereby supporting a more competitive, innovative, affordable, and higher quality healthcare system.
Many of the OPPS Proposed Rule described in our September HotStone were finalized which will serve to increase the compliance burden for hospitals, as well as introduce additional reporting obligations and larger data files. As a result, hospitals must pay close attention to updated mandates and ensure rigorous adherence to all provisions. The key provisions include:
Effective Dates and Enforcement
The final rule takes effect on January 1, 2026, with enforcement delayed until April 1, 2026. A 35% reduction in civil monetary penalties now applies when a hospital waives an ALJ hearing for hospitals that violate the price transparency requirements.
Allowed Amount Calculations
Hospitals are required to report the tenth percentile, median, and ninetieth percentile allowed amounts for payer-specific charges based on a percentage or algorithm, calculated from data covering no less than 12 months and no more than 15 months prior to posting. The total allowed amount should represent the actual reimbursement received for a service, calculated as the gross charge minus contractual adjustments, and includes both the portion paid by insurers and any amount billed to the patient.
In addition, “Should the calculated median fall between two observed allowed amounts, the median allowed amount is the next highest observed value,” as indicated in the final rule. If there are percentages or algorithms that modify the negotiated rate for an individual item or service, hospitals must include the base rate for that item or service in the payer-specific negotiated charge dollar amount field, and a payer specific negotiated percentage or algorithm with encoding of allowed amounts.
Count of Allowed Amounts
Hospitals must now include the total amount of allowed remittances from the EDI 835 electronic remittance data, or equivalent source used to calculate the tenth percentile, median, and ninetieth percentile allowed amounts. Zero-dollar values must be eliminated from the counts.
Report the actual count value when the number of remittances is eleven or greater.
When the count of remittances is greater than zero but less than eleven, encode the value “1 through 10”.
If there are no remittances for the 12–15-month period, encode "0" in the "Count of Allowed Amounts" field and provide an explanation in the "Additional Generic Notes" or “Additional Payer-Specific Notes" depending on file format.
Data Source and Encoding Requirements
Allowed amounts must be sourced from EDI 835 electronic remittance data or an equivalent source containing comparable information. This ensures consistency and accuracy in reporting. The allowance of “equivalent sources” is a deviation from the proposed rule providing hospitals with more leeway in the potential source to use for calculating the allowed amounts.
NPI Reporting Requirements
Hospitals must include all active type 2 NPIs in their machine-readable files, specifically those with primary taxonomy codes beginning with “28” or “27.”
Hospital Attestation and Data Accuracy
Hospitals must update their attestation statements to include the name of the CEO or another senior official responsible for the accuracy of the data. The attestation affirms that the information in the machine-readable file is true, accurate, and complete as of the file’s date. CMS has maintained the language “to the best of its knowledge and belief” in the attestation, reflecting a shift from the proposed rule.
To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.
Conclusion
To meet the latest CMS requirements, SunStone recommends hospitals take a proactive approach by refining their processes for data collection, reporting, encoding, and attestation. CMS has also made additional resources available on its GitHub page to clarify these requirements.
The key actions to take to ensure compliance with the new guidance as of April 1, 2026 include:
Adhering to all specified compliance and enforcement deadlines.
Calculating accurately and disclosing allowed amounts, as well as documenting the corresponding count values.
Relying exclusively on approved electronic data sources, such as EDI 835 files or comparable alternatives, for all reporting.
Properly including all required National Provider Identifiers (NPIs) with the appropriate taxonomy codes in machine-readable files.
Assigning responsibility to a senior executive, such as the CEO or other qualified official, to verify and attest to the completeness and accuracy of pricing data.
By preparing early and thoroughly, hospitals can minimize the risk of enforcement actions and promote greater price transparency for consumers. SunStone has personal hands-on experience with assisting hospitals in the development of Machine-Readable Files. If you have any questions, please contact Kristie Bailey, Director at kristiebailey@sunstoneconsulting.com or Vonda Moon Senior Principal at vondamoon@sunstoneconsulting.com.