Health Insurance Transparency in Coverage PUF

$179 / year

This dataset shows the issuer-level claims, appeals, and active URL data. The PY2018 PUF contains data from PY2016 for issuers participating in the Exchange in PY2016.

Complexity

The Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information & Insurance Oversight (CCIIO) publishes the Transparency in Qualified Health Plan (QHP) Coverage Public Use File (PUF) in order to increase access to QHP issuer data reported pursuant to section 1311(e)(3) of the Affordable Care Act. The Transparency in QHP Coverage PUF includes data on QHPs and Stand-alone Dental Plans (SADPs) offered in states with Federally-Facilitated Exchanges (FFEs), including issuers in the FFEs where states perform plan management functions (SPEs), and State-based Exchanges on the Federal Platform for eligibility and enrollment (SBE-FPs).

The data provided is an aggregate number for plans sold by an issuer on the FFEs, including FFEs where States perform plan management functions, and SBE-FPs only. This information simply provides a raw number and is not a complete description of issuer or plan enrollment. Enrollment is not necessarily indicative of issuer strength or plan quality. Enrollment may change daily due to a variety of circumstances.

Date Created

2016-11-30

Last Modified

2020-02-12

Version

2020-02-12

Update Frequency

Annual

Temporal Coverage

2020

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare and Medicaid Services;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Health Insurance, Insurance Marketplace, Transparency in Coverage PUF, Insurance Rate Review, Insurance Rate Increase, Insurance Market Competition, Health Benefits, Transparency in Coverage, Coverage PUF, Exchange PUFs

Other Titles

Health Insurance Exchange Public Use Files, Qualified Health Plan Transparency in Coverage PUF

NameDescriptionTypeConstraints
State_AbbreviationTwo-character state abbreviation indicating the state where the plan is offeredstring-
Issuer_NameName of the company issuing the planstring-
Issuer_IDFive-digit numeric code that identifies the issuer organization in the Health Insurance Oversight System (HIOS)integerlevel : Nominal
Is_Issuer_New_To_ExchangeIndicate that the issuer is new to exchange or notboolean-
URL_Claims_Payment_PoliciesURL Claims Payment Policies & other Informationstring-
Claims_ReceivedNumber of claims received by an issuer asking for a payment or reimbursement by or on behalf of an in-network health care provider (such as a hospital, physician, or pharmacy) that is contracted to be part of the network for an issuer (such as an HMO or PPO). Claims are counted by date of serviceintegerlevel : Ratio
Claims_DenialsNumber of claims received by an issuer asking for a payment or reimbursement by or on behalf of an in-network health care provider (such as a hospital or doctor) that is contracted to be part of the network for an issuer (such as an HMO or PPO) that the issuer subsequently denied.integerlevel : Ratio
Internal_Appeals_FiledNumber of requests by the insured for internal reviews of grievances involving adverse determinations. An internal review is a process by which the insured may have an adverse determination reviewed by the issuer with respect to a denial of an admission, availability of care, continued stay, or health care service for a coveredperson..integerlevel : Ratio
Number_Internal_Appeals_OverturnedNumber of final adverse determinations overturned upon request for internal review. An internal review is a process by which the insured may have an adverse determination reviewed by the issuer with respect to a denial of an admission, availability of care, continued stay, or health care service for a covered person.integerlevel : Ratio
Percent_Internal_Appeals_OverturnedIssuer-level data at the State level, for all QHPs on Exchange.numberlevel : Ratio
External_Appeals_FiledNumber of requests by the insured for appeals on final adverse determinations to an external review organization.integerlevel : Ratio
Number_External_Appeals_OverturnedNumber of final adverse determinations overturned upon request for external review, in whole or in part.integerlevel : Ratio
Percent_External_Appeals_OverturnedPercent of final adverse determinations overturned (# external appeals overturned/# of external appeals filed) upon request for external review.numberlevel : Ratio
Number_Claims_ReceivedIndicate that number of claims received.number-
Claims_DeniedIndicate that number of claims denied by issuer.number-
Claims_Denied_Referral_RequiredIndicate that number of claims denied for reason referral required.number-
Claims_Denied_Out_of_NetworkIndicate that number of claims denied as out of network.number-
Claims_Denied_Services_ExcludedIndicate that number of claims denied as services excluded.number-
Claims_Denied_Not_Medically_NecessaryIndicate that number of claims denied as not medically necessary.number-
Claims_Denied_Not_Medically_Necessary_Incl_Behav_HealthIndicate that number of claims denied as not medically necessary including behavioral health.number-
Claims_Denied_OtherIndicate that number of claims denied for other reasons.number-
Financial_InformationURL link to prior calendar year issuer-level information about premiums, assets, and liabilities.string-
Enrollment_DataIssuer level cumulative enrollment numbers, as measured by non-canceled plan selections, based on the end of the prior calendar year’s information.integerlevel : Ratio
Disenrollment_DataIssuer level cumulative disenrollment numbers, as measured by canceled plan selections, based on the end of the prior calendar year’s information.integerlevel : Ratio
State AbbreviationIssuer NameIssuer IDIs Issuer New To ExchangeURL Claims Payment PoliciesClaims ReceivedClaims DenialsInternal Appeals FiledNumber Internal Appeals OverturnedPercent Internal Appeals OverturnedExternal Appeals FiledNumber External Appeals OverturnedPercent External Appeals OverturnedNumber Claims ReceivedClaims DeniedClaims Denied Referral RequiredClaims Denied Out of NetworkClaims Denied Services ExcludedClaims Denied Not Medically NecessaryClaims Denied Not Medically Necessary Incl Behav HealthClaims Denied OtherFinancial InformationEnrollment DataDisenrollment Data
AKModa Assurance Company77963Truehttps://www.modahealth.com/members/transparency.shtmlhttps://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47098&:refresh
AKOregon Dental Service21989Falsehttps://www.modahealth.com/members/transparency.shtml8987.02013.04249.01022.0273.0749.0Missing URL850.0411.0
AKOregon Dental Service21989Falsehttps://www.modahealth.com/members/transparency.shtml8987.02013.02992.0677.0167.0510.0Missing URL851.0405.0
AKOregon Dental Service21989Falsehttps://www.modahealth.com/members/transparency.shtml8987.02013.01701.0312.091.0221.0Missing URL245.095.0
AKPremera Blue Cross Blue Shield of Alaska38344Falsehttps://www.premera.com/ak/visitor/transparency-in-coverage/504380.070912.0178.076.00.4311.0https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47570&:refresh
AKBEST Life and Health Insurance Company74819Falsehttp://www.bestlife.com/ak/index.html578.0270.0116.046.019.019.0https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=90638&:refresh115.047.0
AKBEST Life and Health Insurance Company74819Falsehttp://www.bestlife.com/ak/index.html578.0270.076.037.019.0https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=90638&:refresh36.026.0
AKBEST Life and Health Insurance Company74819Falsehttp://www.bestlife.com/ak/index.html578.0270.036.017.012.0https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=90638&:refresh32.021.0
AKBEST Life and Health Insurance Company74819Falsehttp://www.bestlife.com/ak/index.html578.0270.0350.0170.0119.040.0https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=90638&:refresh355.0226.0
ALDental Care Plus, Inc.18239Truehttp://files.dentalcareplus.com/exchange/Transparency-2020.pdfMissing URL