Patient access — estimates & price transparency
Good-faith patient responsibility estimates, CMS price-transparency artifact readiness, and estimate-accuracy monitoring for TRH. The simulator takes benefit parameters only — never a patient — so there is no PHI anywhere in this module.
Basis: Benefit snapshot + contract rate grid — periodic batch, not a real-time eligibility check. An estimate is not a guarantee.
Good-faith estimate simulator
Pick a shoppable service and adjust benefit parameters. The estimate is deterministic and every step is shown — deductible, then coinsurance, then copay, capped at the out-of-pocket maximum.
- 1.Contract allowed amount: $6,820.
- 2.Applied to deductible: min(allowed, $1,500 remaining) = $1,500.
- 3.Coinsurance: 20% of $5,320 post-deductible = $1,064.
- 4.Copay: $0.
- 5.Patient before OOP cap: $2,564.
- 6.OOP maximum not reached — no cap applied.
- 7.Estimated patient responsibility: $2,564; plan pays $4,256.
An estimate is not a guarantee of coverage or final patient responsibility. It is derived from a periodic benefit snapshot and the loaded contract rate grid, not a real-time eligibility check; the snapshot date is always disclosed.
CMS artifact readiness
Machine-readable file and shoppable-services readiness with rate coverage and validation exceptions. Stale artifacts are surfaced against their last refresh.
| Artifact | Status | Rate coverage | Exceptions | Evidence |
|---|---|---|---|---|
CMS machine-readable file (all payers) Machine-readable file · refreshed 2026-07-01 | Published | 97% | 2 | CSV |
300 shoppable services list Shoppable services · refreshed 2026-07-01 | Published | 94% | 5 | CSV |
Consumer estimator rate grid Shoppable services · refreshed 2026-05-15 | Stale | 88% | 11 | CSV |
Estimate vs. adjudicated
Back-tested estimates compared to adjudicated remittance, with variance and a ±10% tolerance band. Every row carries its benefit-snapshot date and 835 evidence reference.
| Procedure | Payer | Estimated | Adjudicated | Variance | Tolerance | Evidence |
|---|---|---|---|---|---|---|
| Level 5 arthroscopy | UnitedHealthcare | $1,420 | $1,510 | +$90 (6%) | Within | 835 batch A · benefit snapshot 05-02 |
| CT abdomen w/ contrast | BCBSTX | $310 | $298 | -$12 (4%) | Within | 835 batch B · benefit snapshot 05-08 |
| Upper GI endoscopy | Aetna | $740 | $910 | +$170 (18.7%) | Out of band | 835 batch A · benefit snapshot 04-19 |
| Level 4 emergency visit | UnitedHealthcare | $262 | $262 | $0 (0%) | Within | 835 batch B · benefit snapshot 05-22 |
Out-of-band variances are routed to the HARS monthly review to determine whether the driver is benefit-snapshot drift or a contract-rate error before the estimator rate grid is refreshed.
Monthly access review
What the VERIFY technology identifies from the snapshot and rate grid, what HARS Advisors validate, what TRH owners decide, and what gets reviewed each cycle.
- ›Rate-grid staleness against the published snapshot date
- ›Estimate-vs-adjudicated variance beyond the 10% tolerance band
- ›Machine-readable file validation exceptions and coverage gaps
- ›Whether a variance is a benefit-snapshot drift or a contract-rate error
- ›Root cause of stale artifacts before re-publication
- ›That disclosures (snapshot date, not-a-guarantee) are intact
- ›Refresh cadence for the consumer estimator rate grid
- ›Which service lines need tighter benefit-snapshot frequency
- ›Publication sign-off for the CMS machine-readable file
- ›Estimate accuracy rate vs. tolerance target
- ›Transparency artifact status (published / stale / exception)
- ›Open validation exceptions and their owners
No patient identifiers are collected, shown, or stored. The simulator operates on benefit parameters only. Harsight combines periodic batch technology with HARS Advisors — this module is not a real-time eligibility feed.