How a Payer Deletes You From Its Price File

If you run payer relations, you already pull the machine-readable files. This morning the rule that governs them got rewritten.

Transparency in Coverage published at 91 FR 63748, 120 pages, jointly finalized by Treasury, Labor and HHS as CMS-9882-F, effective December 7, 2026. The trade will lead on file size, which is fair, since shrinking the files is most of what the Departments say they were doing.

The provision worth your afternoon is a new paragraph (F). What it does is delete you.

Who Gets Deleted

New 45 CFR 147.212(b)(1)(i)(F), with twins at 26 CFR 54.9815-2715A3 and 29 CFR 2590.715-2715A3:

"A group health plan or health insurance issuer must exclude from each file ... a provider and their negotiated rate (provider-rate combination) for an item or service if the plan or issuer determines it is unlikely that the provider would be reimbursed for the item or service given that provider's specialty according to the plan's or issuer's internal provider taxonomy or other internal rules used during the claims adjudication process."

Read the back half twice. The filter is the payer's own claims adjudication logic, pointed at the public price file.

The Departments offer the easy version: a plan's internal taxonomy "would be unlikely to reimburse a claim submitted for a heart surgery submitted from a podiatrist." Sure. The mechanism does not stop at podiatrists doing cardiac surgery, because the mechanism is whatever your payer's specialty edits already say, including the ones you argue with every quarter.

And where a combination comes out, (b)(1)(i)(E)(2) pulls the NPI, TIN and Place of Service Code with it. You do not show up at a zero. You do not show up.

Two limits, both real:

• The exclusion has to rest on specialty. The preamble says it "does not include an unlikely reimbursement based on other reasons, such as a dormancy period," so a payer cannot drop a code pair because you have not billed it lately.
• The determination "must be made consistent with applicable law," and the Departments name PHS Act section 2706(a), the provider nondiscrimination clause, in the text.

What the rule never does is audit the mapping itself. In the Departments' own words, these rules "do not require plans and issuers to make any changes [to] their claim adjudication processes."

The File That Says Why

Here is the part to walk into the CFO's office with.

Paragraph (b)(2)(ii) creates a Taxonomy File. Every plan and issuer has to publish, machine-readable, the internal taxonomy "or other internal rules" it uses "to determine if the plan or issuer should deny reimbursement for an item or service based on the provider's specialty."

In a form you can actually join: "pairings of items and services (represented by billing codes) with provider specialties (represented by specialty codes which are derived from the Health Care Provider Taxonomy code set established by the National Uniform Claim Committee (NUCC))."

That is the 883-code NUCC set we ran on September 13 on one side, and CPT and HCPCS on the other. Your payer's specialty denial map, free, quarterly, keyed to the same ten characters that already sit on your claims.

Payers running something other than taxonomy logic get no pass. The preamble tells them they "may need to convert their internal rules into data suitable to be submitted in the Taxonomy File."