A reference guide to understanding negotiated rate data, navigating common challenges, and using the HexIQ platform effectively.
The Transparency in Coverage (TiC) Rule requires commercial payers to publish their negotiated rates with every contracted provider. Each published rate record contains these key data elements:
| Element | Description |
|---|---|
| TIN | Tax Identification Number identifying the billing entity. Can be an EIN (assigned by the IRS to organizations) or an NPI (assigned by CMS to providers). |
| NPI | National Provider Identifier for the individual or organization providing the service. |
| Billing Code | The CPT or HCPCS code identifies the specific service (e.g., 78451 = Myocardial Perfusion Imaging). |
| Modifier | An optional modifier that changes how the service is billed (e.g., modifier 26 = professional component only). |
| Place of Service | Where the service is rendered (e.g., 11 = Office, 22 = Outpatient Hospital). |
| Negotiated Rate | The contracted dollar amount the payer has agreed to pay for this service. |
A single organization can appear in the data in multiple ways. Here are two examples using Cardiovascular Specialists of Frederick, showing real rate records from UnitedHealthcare:
| TIN | NPI | Code | Modifier | Service Code | Rate |
|---|---|---|---|---|---|
| Cardiovascular Specialists of Frederick (52-2144172) | Cardiovascular Specialists of Frederick (1922034461) | 78451 | N/A | 11 | $414.33 |
The TIN is the organization's EIN. The NPI is a Type 2 (organization) NPI. This represents the organization-level negotiated rate.
| TIN | NPI | Code | Modifier | Service Code | Rate |
|---|---|---|---|---|---|
| Cardiovascular Specialists of Frederick (52-2144172) | Dr. Sumit Duggal (1386806784) | 78451 | N/A | 11 | $414.33 |
| Cardiovascular Specialists of Frederick (52-2144172) | Dr. Sumit Duggal (1386806784) | 78451 | N/A | 11 | $332.79 |
Same TIN, same individual provider, same CPT code, but two different negotiated rates. This happens when there are multiple contract arrangements, such as different plan tiers or rate groups within the same payer.
A negotiated rate is always tied to a specific TIN + NPI + billing code combination. The same organization or provider can have different rates depending on which TIN is used for billing, which payer published the data, and which contract arrangement applies.
| Term | Definition |
|---|---|
| TIN | Tax Identification Number. In TiC data, this identifies the billing entity. It can be an EIN or a Type 2 NPI (payers choose which to use, and practices may vary across payers). |
| EIN | Employer Identification Number. A 9-digit number (formatted XX-XXXXXXX) assigned by the IRS to organizations. The most common TIN type in TiC data. |
| NPI (Type 1) | National Provider Identifier assigned to an individual clinician. Permanent and portable (it follows the provider across employers and practices throughout their career). |
| NPI (Type 2) | National Provider Identifier assigned to an organization such as a practice, hospital, or group. Some payers use Type 2 NPIs as the TIN in their rate filings. |
| CPT Code | Current Procedural Terminology. A standardized code identifying a specific medical service or procedure (e.g., 97110 = Therapeutic Exercise, 99214 = Office Visit). |
| Taxonomy Code | A classification code identifying a provider's specialty and type (e.g., 225100000X = Physical Therapist, 207R00000X = Internal Medicine). |
| Payer | The insurance company that published the rate data. HexIQ identifies payers by a numeric Payer ID (e.g., UnitedHealthcare = 200, Cigna = 191, Aetna = 170). |
| Place of Service | A code indicating where the service is rendered. Common values: 11 (Office), 22 (Outpatient Hospital), 21 (Inpatient Hospital). |
| Billing Class | Whether the rate covers the professional component (the physician's work) or the facility component (the hospital or facility's overhead). |
| Negotiated Rate | The specific dollar amount a payer has contractually agreed to pay a provider for a given service. This is the core data element in TiC filings. |
| IPA | Independent Physician Association. A network of independent physicians who contract together to negotiate with payers. An IPA's TIN may appear in rate data in place of an individual practice's EIN. |
| MSO | Management Services Organization. Provides billing and administrative services to medical practices, and bills payers using the MSO's TIN on behalf of the practices it serves. |
There are six common reasons why finding a specific organization's negotiated rates in TiC data is not straightforward.
The TiC Rule requires that every published rate be associated with a TIN and an NPI, but it allows payers to choose what to use as the TIN:
Different payers make different choices, even for the same organization. This means the same practice may appear under an EIN with one payer and under individual NPIs with another.
Type 1 NPIs are permanent and portable, following an individual clinician throughout their career. But payer systems often fail to fully retire old contractual relationships. As a result, a clinician's NPI may still appear linked to former group practices, acquired entities, or organizations that have closed.
These outdated rates remain published even when the provider no longer bills under that organization. This creates the appearance that multiple organizations are actively contracted when only one is current.
During acquisitions, mergers, or employment changes, old contracts may remain temporarily in force while new contracts begin in parallel. Both sets of rates can appear in TiC data simultaneously, each valid within its contractual window.
Many providers are legitimately contracted under more than one legal entity:
This means the same Type 1 NPI can appear under multiple TINs, with rates that are contractually valid but context-specific to a particular billing arrangement.
Healthcare organizations often operate with parent holding companies, subsidiaries with distinct EINs, and facility-level Type 2 NPIs registered as sub-parts. Payers may publish rates at any level of this hierarchy without indicating:
While NPIs are centrally issued by CMS, the maintenance of NPI records is provider-driven. Common issues include:
When TiC files rely on this metadata for identification, rate attribution inherits those gaps.
HexIQ provides five methods for identifying an organization's contracted rates. The best approach depends on what information you already have.
When to use: You know the organization's EIN or TIN.
Enter relevant CPT codes and your known TIN(s) to find rates for all associated NPIs across all payers. This is the most direct approach, but it only works for payers that filed rates using this specific TIN.
https://my.pulse.app/advanced-search?associated=201731332&codes=99285
When to use: You want to see which providers bill under a specific TIN.
Look up all NPIs associated with a known TIN to understand who bills under that identifier. This helps you assess whether a TIN represents the organization directly, an IPA, or an MSO.
https://my.pulse.app/providers?associated=262559916
When to use: The organization's direct TIN returns no results, or you want to discover additional TINs.
Enter relevant CPT codes and your known NPI(s) to find rates across all potentially associated TINs and payers. This is often the most reliable approach because individual NPIs (Type 1) are consistent across all billing arrangements.
When to use: You want to find all providers in a specific specialty and geographic area.
Search for relevant CPT codes filtered by taxonomy code, payer(s), and location (state, or a radius around an address). This returns all providers matching the criteria across all payers, which is useful for competitive analysis and for discovering providers you may not have known about.
When to use: You want to visualize the competitive landscape and discover contractual relationships.
View all providers in a specific taxonomy, payer, and radius around an address as a network graph. Organization TINs and individual NPIs appear as connected nodes, making it easy to see which providers are grouped together and identify competitors.
TiC data covers the majority of commercial health plan rates, but gaps can occur. Common reasons your rates may be missing or incomplete:
If any method does not return data as expected:
When a practice contracts through an IPA or uses an MSO for billing, the IPA/MSO's TIN can appear in payer data instead of the practice's own EIN. This is the most common reason a practice's direct EIN returns no results for certain payers.
A network of independent physicians who contract together to negotiate with health plans. Physicians remain independent but share administrative resources and payer contracts. IPAs handle managed care contracting, utilization management, and quality programs. They allow small practices to compete with large health systems for favorable payer contracts.
Provides administrative and back-office services to medical practices, including billing, credentialing, IT, HR, compliance, and claims processing. The MSO bills payers on behalf of the practices using the MSO's TIN. Practices keep clinical independence while outsourcing business operations.
If you're having trouble locating your organization's rates or understanding your data, reach out to the HexIQ support team:
Email: support@hexiq.com
Phone: +1 (833) 439-4742