Background

Boulder Administration Services (BAS) is a Third-Party Administrator (TPA) based in Boulder, Colorado, that provides healthcare benefits administration services to self-funded employers. As a TPA, BAS manages health plan benefits on behalf of employer groups, handling claims processing, member services, and regulatory compliance.

In 2020, the Centers for Medicare & Medicaid Services (CMS) finalized the Transparency in Coverage (TiC) Rule, which requires health insurers and self-funded group health plans to publicly disclose pricing information. The rule mandated that plans make available machine-readable files (MRFs) containing in-network rates and out-of-network allowed amounts, as well as a member-facing cost-estimation tool — commonly referred to as a “shopping tool” — so that members could look up cost estimates for covered services before receiving care.

The compliance deadlines for the TiC Rule were staggered: MRF publication requirements took effect on July 1, 2022, while the shopping tool requirement for 500 shoppable services became effective January 1, 2023, and the all-services shopping tool requirement became effective January 1, 2024.

BAS needed a robust, scalable, and user-friendly solution that would allow their employer clients and plan members to meet these regulatory mandates. They turned to Deerhold for help.

Challenge

BAS faced several interconnected challenges in achieving TiC compliance:

1. Data Complexity and Volume: The TiC Rule requires the disclosure of negotiated rates for all covered items and services across all in-network providers. For a TPA like BAS, this involved aggregating and processing enormous volumes of claims and rate data from multiple payers, networks, and provider organizations. The sheer scale and heterogeneity of this data made ingestion, normalization, and presentation a significant technical challenge.
2. Regulatory Precision: The TiC Rule is highly specific in its requirements — including file formats, data elements, and update frequencies for MRFs, as well as functionality requirements for the member-facing shopping tool. Any deviation from these specifications could result in regulatory penalties and reputational damage for BAS and their employer clients.
3. User Experience: While the regulatory requirements focused on data disclosure, BAS understood that compliance alone was not enough. A shopping tool that was difficult to use would fail to deliver value to plan members. BAS needed a solution that was not only compliant but also intuitive and genuinely helpful for members seeking cost estimates.
4. Speed to Market: With regulatory deadlines looming, BAS needed to move quickly. They required a partner with both technical depth and healthcare domain expertise who could deliver a production-ready solution on a compressed timeline.

Solution: PRIZM Shopping

Deerhold developed and delivered PRIZM Shopping, a purpose-built, cloud-native platform designed specifically to address the requirements of the TiC Rule. PRIZM Shopping is a comprehensive solution that encompasses both the back-end data infrastructure needed to ingest, process, and serve TiC data at scale, and the front-end member experience that enables intuitive cost estimation.

PRIZM Shopping was architected to ingest MRF data from multiple sources — including network operators, payers, and BAS's own claims data — normalize it to a consistent internal schema, and make it queryable in real time via a high-performance API layer. The platform was built on AWS infrastructure, leveraging services such as S3 for MRF storage, Lambda and ECS for serverless and containerized compute, RDS and DynamoDB for relational and NoSQL data storage, and CloudFront for global content delivery.

The member-facing shopping tool provided by PRIZM Shopping allows plan members to search for a procedure or service, select their plan, specify a geographic area, and receive a cost estimate based on their specific benefits — including deductible, out-of-pocket maximum, copay, and coinsurance — applied against the negotiated rates for in-network providers in their area.

Results

1. Full Regulatory Compliance: BAS achieved compliance with all applicable TiC Rule requirements, including MRF publication and shopping tool availability, ahead of the relevant regulatory deadlines. BAS and their employer clients avoided potential CMS penalties and demonstrated their commitment to transparency to their members.
   1. MRFs published on schedule and updated monthly as required
   2. Shopping tool covering all 500+ shoppable services launched by January 1, 2023 deadline
   3. All-services shopping tool launched by January 1, 2024 deadline
   4. Zero CMS enforcement actions or penalties for BAS or their employer clients
2. Scalable Data Infrastructure: PRIZM Shopping's cloud-native architecture allowed BAS to onboard new employer clients and expand their covered lives without significant incremental infrastructure investment. The platform handled peak query loads during open enrollment periods without degradation in performance.
   1. Processed and indexed MRF data for multiple large network operators covering millions of in-network provider-service combinations
   2. Sub-second query response times for member cost estimation requests
   3. Handled 10x traffic spikes during open enrollment without service interruption
3. Member Engagement: The PRIZM Shopping member experience was well-received by BAS's employer clients and their plan members. Members reported that the tool was easy to use and provided cost information that helped them make more informed decisions about their care.
   1. High member satisfaction scores for the shopping tool experience
   2. Increased member engagement with cost estimation prior to scheduled procedures
   3. Positive employer client feedback citing improved member experience as a differentiator in benefits administration
4. Competitive Differentiation: By partnering with Deerhold and deploying PRIZM Shopping, BAS was able to offer a best-in-class TiC compliance solution to their employer clients — a capability that smaller TPAs often struggled to deliver independently. This enhanced BAS's competitive position in the TPA market and supported their business development efforts.
   1. New employer client wins citing PRIZM Shopping as a key factor in their selection of BAS
   2. Retention of existing employer clients who cited the quality of the TiC solution as a reason for renewing their TPA relationship

Implementation Highlights

1. Discovery and Requirements: Deerhold began the engagement with an intensive discovery phase, working closely with BAS's compliance, operations, and technology teams to understand their specific TiC obligations, their existing data infrastructure, and their priorities for the member shopping experience.
   1. Comprehensive review of BAS's existing claims and eligibility data systems
   2. Analysis of network operator MRF formats and data quality
   3. User research with BAS's employer clients and plan members to inform shopping tool UX design
2. Agile Development: PRIZM Shopping was developed using an agile methodology with two-week sprints. Deerhold maintained close communication with BAS throughout the development process, providing regular demos and incorporating BAS's feedback into each sprint cycle.
   1. Bi-weekly sprint reviews with BAS stakeholders
   2. Continuous integration and continuous deployment (CI/CD) pipeline enabling rapid iteration
   3. Automated testing suite covering MRF ingestion, benefits calculation logic, and shopping tool functionality
3. Data Integration: A significant portion of the implementation effort was devoted to building robust, reliable integrations with BAS's data sources and the network operators' MRF publishing infrastructure.
   1. Custom MRF ingestion pipelines for multiple large network operators
   2. Integration with BAS's eligibility and benefits data systems for real-time member-specific cost estimation
   3. Automated monitoring and alerting for MRF ingestion failures and data quality issues
4. Compliance Validation: Prior to launch, Deerhold conducted extensive compliance validation testing to confirm that PRIZM Shopping met all applicable TiC Rule requirements.
   1. End-to-end validation of MRF format and content against CMS technical specifications
   2. Functional testing of the shopping tool against the full list of 500+ shoppable services required by the TiC Rule
   3. Penetration testing and security review to protect member data

Conclusion

The Transparency in Coverage Rule represents a significant regulatory shift in the U.S. healthcare market, requiring health plans and their administrators to expose pricing data at a level of granularity and accessibility that was previously unavailable to consumers. For TPAs like Boulder Administration Services, meeting this challenge required both technical sophistication and deep healthcare domain expertise.

By partnering with Deerhold and deploying the PRIZM Shopping platform, BAS was able to achieve full regulatory compliance while simultaneously delivering a member experience that added genuine value for their employer clients and plan members. The engagement demonstrated Deerhold's ability to deliver complex, data-intensive healthcare technology solutions on compressed timelines — and BAS's willingness to embrace innovative technology partnerships to stay ahead of the regulatory curve.

As the healthcare transparency landscape continues to evolve, Deerhold and BAS remain committed to their partnership and to delivering solutions that empower consumers to make more informed healthcare decisions.