Hospital price transparency
Payer contract data gaps
The negotiated charge lives in payer contracts, not the chargemaster. CMS has said so directly: rate tables and rate sheets in in-network contracts are where the payer-specific negotiated charge is found. A file-building process that cannot reach contract data will produce a file with systematic holes, and the holes cluster by payer.
The CY 2026 rule added a second dependency on remittance data. When a negotiated charge is expressed as a percentage or algorithm that cannot be fully reduced to a dollar amount, the file must carry the median, 10th and 90th percentile allowed amounts and the count behind them, calculated from a contiguous lookback of 12 to 15 months. The source is EDI 835 remittance data or an equivalent with the same detail, at payer and plan level.
Hospitals without usable 835 detail are directed to other actual remittance data - revenue cycle systems, EHRs, payer portals, clearinghouses - as long as it supports the total allowed amount: gross charge minus contractual adjustments, split into the payer and patient portions.
These requirements are effective January 1, 2026, with CMS delaying enforcement of the new elements until April 1, 2026. A data gap that was an inconvenience in 2025 is a named deficiency after that date. The work is mapping every payer and plan to a data source before the lookback math is due, not after.