Payer
Data Dictionary
Every column in our payer transparency (TiC) exports — what it means and how we derive it.
Column added or derived by Serif Health
No columns match your search.
Payer & Network
- Full payer name (e.g., “Blue Cross Blue Shield of Alabama”).
- The state abbreviation (e.g., "TX", "CA"), or "USA" for national.Methodology: If the plan name in the table of contents or the plan_id includes a HIOS state code, this is used to determine NetworkRegion. If ambiguous, we may use web searches or other sources to identify the network region.
- Full network name where delineated by payer MRF index (e.g., “Blue Choice Platinum for Business - PPO”).Methodology: We keep the plan_name indicated in the table of contents file if fully defined; if not or ambiguous we may use web searches or other sources to identify the plan name.
- The yyyymm year month of this MRF posting.Methodology: We use the month and year of the _index_ file, if unambiguous. If not present or obvious, we will use the month and year indicated in the in-network file name, and if that is not present or obvious, we will match it to the year and month of access.
- The date the source MRF file was accessed (i.e., downloaded from the payer and converted).
Entity & Provider
- The name of the organization, practice group, or provider that was resolved.Methodology: Name tables come from NPPES as well as proprietary and public sources like EDGAR filings, IRS notices, legal filings, etc.
- Based on the type of entity (organization, practice group, or provider) that is resolved for the record, it takes on one of the following values: "TIN", "Type 2 NPI", "Imputed Type 2 NPI", or "Type 1 NPI". Matching is prioritized in this order.Methodology: Our approach is to resolve the entity name and address using the following waterfall:
- First, aim to match on TIN (or the value in the "EIN" column).
- If TIN is not present, then we aim to match on the first Type 2 NPI we see in the "NPI-List" column).
- If a Type2 NPI match also fails, then we try to impute a Type 2 NPI by seeing if the EIN in the "EIN" column corresponds to one and only one Type2NPI.
- If all matches fail, then we match on the first Type1 NPI we see in the NPI-list.
- The identifier (TIN or NPI) of the organization, practice group, or provider that was resolved.
- Will be a 9 digit un-hyphenated EIN or a 10 digit NPI number, each payer may use either format. EINs can be zero-led so this must be a text field.
- A comma-separated list of 10 digit NPIs filtered by search criteria.
- Count of NPIs in PayerNPIList. Count may differ from PayerSourceNPIListLength due to zombie rate elimination (i.e., NPIs with identified zombie rates are removed).
- Count of distinct, unfiltered NPIs published by payers in the raw MRF data source for a given network_id, EIN, and code.
- Count of distinct credentialed type 1 (individual-provider) NPIs linked to the EIN for the selected network, with no filters applied.Methodology: For the selected network, we search all NPI lists to identify the total count of distinct type 1 (individual-provider) NPIs associated with an EIN
- Count of distinct credentialed type 2 (organization-provider) NPIs linked to the EIN for the selected network, with no filters applied.Methodology: For the selected network, we search all NPI lists to identify the total count of distinct type 2 (organization-provider) NPIs associated with an EIN
- An NUCC primary taxonomy code such as "207X00000X".Methodology: The most common NUCC primary taxonomy code for the NPIs in the npi_list field. The primary taxonomy for each NPI is obtained using NPPES.If a filter for "taxonomy" is set, then Signal will only return groups where the majority of the npi-list belongs to that taxonomy.
- A description for the taxonomy such as "Orthopedic Surgery".Methodology: Tables from https://nucc.org/
- The state abbreviation (e.g., "TX", "CA").Methodology: This is the most common state across all NPIs in the source npi_list from the MRF. The state for each NPI is obtained using NPPES.If a filter for "region" is set, then Signal will only return groups where the majority of the npi-list belongs to that region.
- The relevant CBSAs within the npi_region.Methodology: This will only be populated if a user selects CBSA filters within Signal.
- The address of the organization, practice group, or provider that was resolved.
Billing Code
- CodeSThe specific service being priced.Methodology: Normalized billing code to be zero-led and hyphens removed. MS-DRG will always be three characters, RC 4 characters, APR DRG 4 characters.Note: If a custom code has been cross-walked to another code by Serif Health (e.g., EMR3 > 99283), the cross-walked code will show up in this field.
- A higher-level billing code group category (e.g., code 27447 maps to Surgery).Methodology: Code group categories defined using clinical service categories derived from claims data.
- A more specific billing code group subcategory (e.g., code 27447 maps to Musculoskeletal System).Methodology: Code subgroup categories defined using clinical service subcategories derived from claims data. When a code qualifies for multiple subgroups under its group, all matching subgroups are concatenated alphabetically with a / separator, so a code can reflect multiple clinical contexts within a single parent group.
- E.g., CPT, HCPCS, DRG, CSTM.Methodology: All caps is enforced.
- Relevant schedule / year of release for "code_type".Methodology: New CPT codes release each year so values will be '2023', '2024', etc. DRG codes version up using a numeric system (e.g., V38, V41, etc.).
- The specific service being priced (as posted in the payer’s MRF).Methodology: This field will always represent the code found on the MRF whether or not it has been modified or crosswalked to another code in some way.
- E.g., CPT, HCPCS, DRG, CSTM.Methodology: This field will always represent the code found on the MRF whether or not it has been modified or crosswalked to another code in some way.
- Indicates whether the ‘code’ for the record has been imputed / crosswalked from the payer’s original posting.Methodology: If a ‘code’ has been imputed / crosswalked by Serif Health, this field will indicate ‘TRUE’.
- Descriptions included here: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00003604.Methodology: The list values are sorted and a space is added after each comma between values.
- Only relevant for bundled arrangements or capitated contracts. Contains full set of codes included in bundle or contract.
- "Institutional" indicates facility fees and "professional" indicates clinician / doctor fees.Methodology: All lower case is enforced.
- CMS place of service codeset: https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets.Methodology: Extracted from 'service_code' or 'service_codes' (which can be a string or array) in source MRF. The list values are sorted and a space is added after each comma between values.
Rate & Arrangement
- For negotiated_type there are five allowable values: "negotiated", "derived", "fee schedule", "percentage", and "per diem". The value are defined as:
- negotiated: If applicable, the negotiated rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider, except for prescription drugs that are subject to a fee-for-service reimbursement arrangement, which must be reported in the prescription drug machine-readable file. If the negotiated rate is subject to change based upon participant, beneficiary, or enrollee-specific characteristics, these dollar amounts should be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant, beneficiary, or enrollee-specific characteristics.
- derived: If applicable, the price that a plan or issuer assigns to an item or service for the purpose of internal accounting, reconciliation with providers or submitting data in accordance with the requirements of 45 CFR 153.710(c).
- fee schedule: If applicable, the rate for a covered item or service from a particular in-network provider, or providers that a group health plan or health insurance issuer uses to determine a participant’s, beneficiary’s, or enrollee’s cost-sharing liability for the item or service, when that rate is different from the negotiated rate.
- percentage: If applicable, the negotiated percentage value for a covered item or service from a particular in-network provider for a percentage of billed charges arrangement. Note: percentage values entered into the negotiated_rate attribute are to be a whole number percentage of the negotiated arrangement (i.e. 40.5% should be entered as 40.5 and not .405).
- per diem: If applicable, the per diem daily rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider.
Methodology: All lower case is enforced. - An indication as to whether a reimbursement arrangement other than a standard fee-for-service model applies. Allowed values: "ffs", "bundle", or "capitation".Methodology: All lower case is enforced.
- The date on which the agreement for the negotiated rate ends.Methodology: In practice, this field is typically blank or set to a default value of 9999-12-31.
- If the payer posts any additional context on the rates, we include them here.Methodology: "Empty" and "NULL" string values are truncated to an empty string.
- A tri-state (boolean true, false, or NULL) indication of whether this code is billable by the given provider's primary taxonomy.Methodology: Generated using a probabilistic claims analysis, evaluating which provider primary taxonomies bill this particular billing code in the real world. If any NPI in the list is allowed to bill the code, IsBillablePrimaryTaxonomy will be true. If no NPI bills the code, it will be false. If no taxonomy is available, or we have no claims data for this particular code or CodeType, the field will be null.
- A tri-state (boolean true, false, or NULL) indication of whether this code is billable by the given provider's secondary taxonomy.Methodology: Generated using a probabilistic claims analysis, evaluating which provider secondary taxonomies bill this particular billing code in the real world. If any NPI in the list is allowed to bill the code, IsBillableSecondaryTaxonomy will be true. If no NPI bills the code, it will be false. If no taxonomy is available, or we have no claims data for this particular code or CodeType, the field will be null.
- True when the "PayerNPIList" contains any NPIs that were observed to have billed the code in Serif Health's claims data. Note that if the code_type is RC, MS-DRG, or CSTM-ALL, this will always be TrueMethodology: We use our claims database to verify whether the NPIs published by payers have billed the code for a listed reimbursement rate in practice.
- The claims-observed provider billed charge amount.
- The total reimbursement, inclusive of both the patient's and payer's share of cost (as indicated in the payer’s MRF).Methodology: Rate rows with price equal to zero, < 1 dollar, > 100000000, and scientific notation are dropped.
- RateSTotal reimbursement after any calculations performed by Serif Health from the rate posted by the payer.Methodology: If no calculations are applied, this field will match ‘mrf_rate’.
- The payer percentage translated into a dollar amount using the claims-observed billed charge amount.
- A tri-state (High, Mid, Low) indication of whether a rate is an MD (High), PhD/NP (Mid), or MA (Low) rate.Our system will only label the rate tier associated with the maximum npi-list-length.Aetna will often copy/paste the same NPI list for multiple rate tiers for a given code and billing class. This helper column aims to disambiguate Aetna rates for all 9 codes (CPT codes that start with a 9). Read more here about our Aetna rate tier feature.Methodology: A rate tier is only included if there's a presence of at least 2 out of 3 rates that follow the 100%-85%-75% rate ladder. Otherwise, the rate tier value is blank.Rate tier calculation:
- High = 100% of MD rate (+/- 1.5%)
- Mid = 85% of MD rate (+/- 1.5%)
- Low: 75% of MD rate (+/- 1.5%)
- A description of the rate tier as a % of the MD rate.Methodology: Description definition:
- "~100% of MD Rate" = 100% of MD rate (+/- 1.5%)
- "~85% of MD Rate" = 85% of MD rate (+/- 1.5%)
- "~75% of MD Rate" = 75% of MD rate (+/- 1.5%)
Hospital Validation
- The Serif Health hospital MRF identifier matched to the payer rate during payer-to-hospital MRF rate validation. This identifier varies with each unique MRF posting from a hospital.
- The Serif Health hospital identifier for the matched hospital location during payer-to-hospital MRF rate validation. This is a persistent identifier that remains constant across different MRF postings for a hospital.
- The Serif Health hospital record identifier that can be used to identify the record used for the HPT comparison in Serif Health's hospital MRF data library.
- The matched hospital negotiated dollar amount from hospital price transparency data.Methodology: Joined from Serif Health hospital MRF data as standard_charge_negotiated_dollar.
- The matched hospital negotiated percentage amount from hospital price transparency data.Methodology: Joined from Serif Health hospital MRF data as standard_charge_negotiated_percentage.
- The matched hospital gross charge from hospital price transparency data.Methodology: Joined from Serif Health hospital MRF data as standard_charge_gross.
- The hospital negotiated percentage translated into a dollar amount using the gross charge from the HPT record.Methodology: The negotiated percentage from the hospital MRF multiplied by the gross charge from the hospital MRF.
- The payer allowed amount percentage translated into a dollar amount using the gross charge from the HPT record.Methodology: The allowed amount percentage from the payer MRF multiplied by the gross charge from the hospital MRF.
- The relative absolute difference between the payer and hospital reimbursement (rate or percentage).Methodology: If the hospital rate is $100 and the payer-stated rate is $105, the hpt_comparison_diff will be 0.05 (absolute value of the ratio of the rates minus 1).
- High, medium, or low based on HPTComparisonDiffMethodology: High: 0-5%Medium: 5-30%Low: 30+% difference
- A text label describing how the payer and hospital values were compared. If the payer posted a percentage and the hospital posted a dollar value (or vice versa), the percentage would be translated using the gross charge on the HPT data for comparison.Possible values:
- Payer=Dollar | Hospital=Dollar
- Payer=Dollar | Hospital=Percent
- Payer=Percent | Hospital=Dollar
- Payer=Percent | Hospital=Percent
Claims Validation
- Whether the payer-posted dollar rate matched a claims-observed rate within tolerance.Methodology: True when the relative difference between the payer rate and claims rate (associated with the claims_rate_column) is within a 5% tolerance. Only for claims validation and not for billed charges.
- The relative absolute difference between the payer and claims-observed rates. Null when there is no verified dollar-to-dollar claims match.Methodology: If the claims rate is $100 and the payer-stated rate is $105, the claims_comparison_diff will be 0.05 (absolute value of the ratio of the rates minus 1). Only for claims validation and not for billed charges.
- A text label describing how the payer and claims values were compared. Possible values: Payer=Dollar|Claims=Dollar, Payer=Percent|Claims=Dollar.
- The total claim count backing the matched claims observation. Null when there is no verified dollar-to-dollar claims match.Methodology: Only for claims validation and not for billed charges.
- The claims rate column (e.g. plan_allowed_amount, plan_paid_amount) matched to the payer rate during payer-to-claims rate validation. Null when there is no verified dollar-to-dollar claims match.
Benchmarks
- The maximum rate within the same network_id, source_group_id (unique identifier of ein and original payer-published npi list), billing_class, and code.
- True when the row's rate equals source_group_max_rate; otherwise False.
- The row's rate as a percentage of source_group_max_rate. It shows how close the row's rate is to the source_group_max_rate.Methodology: Rate divided by source_group_max_rate.
- The maximum rate within the same network_id, ein, billing_class, and code.
- True when the row's rate equals ein_max_rate; otherwise False.
- The row's rate as a percentage of ein_max_rate. It shows how close the row's rate is to the ein_max_rate.Methodology: Rate divided by ein_max_rate.
- True when the source_group_id (unique identifier of ein and source npi list) has the highest source_npi_list_length among rows with the same network_id, ein, billing_class, and code; otherwise False.In practice, it identifies the source group with the most NPIs for a network_id/ein/billing_class/code combination.
Baseline
- The baseline rate for the given code, modifier, place of service, and billing class combination.Methodology: We update our baseline rate tables annually or quarterly by pulling the tables directly from CMS.
- A string indicating the baseline schedule used to generate the baseline.Methodology: By default, Serif Health uses the fields in each row to select the most appropriate CMS baseline schedule. IPPS, OPPS, Lab, Drug ASP, Anesthesia, and ASC schedules are supported and display their national payment amount for the billing code. For PFS, a MAC is selected by mapping each NPI in the NPIList to a MAC; the most common MAC value is used to set the baseline. If a MAC cannot be mapped, the PFS national payment amount value is used.
- The ratio of the rate divided by the baseline. When the baseline is a CMS-dictated dollar payment amount, this column represents "percent of CMS" for the relevant baseline schedule. When the baseline is a weight, this column represents a "base rate" commonly used for negotiating inpatient or anesthesia pricing.Methodology: Decimal division of the rate by the baseline. If the baseline column is not populated for the given record, this column will be blank.
- Effective year-month of the CMS baseline (if applicable)
- MAC locality of the CMS baseline (if applicable)
- True/False on whether the CMS baseline is a non-facility rate or facility rate (if applicable)
- CCN of the CMS baseline (if applicable)
- Modifier of the CMS baseline (if applicable)
Anesthesia
- Indicates which conversion factor methodology the payer uses to post anesthesia-specific rates.Potential methodologies include:
- MRF rate = conversion rate
- MRF rate = conversion rate * (base unit + time unit)
- N/A
Methodology: If a methodology is present, this means Serif Health has been able to identify the methodology that a particular payer utilizes to post anesthesia-specific rates based on various machine learning models. - Indicates assumed anesthesia base units for the overall rate (between 0 - 30).Methodology: Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units)
- Indicates assumed anesthesia time units for the overall rate (between 0 - 10).Methodology: Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units)
- Indicates assumed anesthesia conversion rate for the overall rate (between 10 - 550).Methodology: Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units)
- Indicates assumed overall rate for an anesthesia-related code.Methodology: Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units)
| Column | Description | Methodology |
|---|---|---|
| Payer & Network | ||
| PayerS | Full payer name (e.g., “Blue Cross Blue Shield of Alabama”). | — |
| NetworkRegionS | The state abbreviation (e.g., "TX", "CA"), or "USA" for national. | If the plan name in the table of contents or the plan_id includes a HIOS state code, this is used to determine NetworkRegion. If ambiguous, we may use web searches or other sources to identify the network region. |
| NetworkNameS | Full network name where delineated by payer MRF index (e.g., “Blue Choice Platinum for Business - PPO”). | We keep the plan_name indicated in the table of contents file if fully defined; if not or ambiguous we may use web searches or other sources to identify the plan name. |
| NetworkYearMonthS | The yyyymm year month of this MRF posting. | We use the month and year of the _index_ file, if unambiguous. If not present or obvious, we will use the month and year indicated in the in-network file name, and if that is not present or obvious, we will match it to the year and month of access. |
| DateAccessedS | The date the source MRF file was accessed (i.e., downloaded from the payer and converted). | — |
| Entity & Provider | ||
| EntityNameS | The name of the organization, practice group, or provider that was resolved. | Name tables come from NPPES as well as proprietary and public sources like EDGAR filings, IRS notices, legal filings, etc. |
| MatchedOnS | Based on the type of entity (organization, practice group, or provider) that is resolved for the record, it takes on one of the following values: "TIN", "Type 2 NPI", "Imputed Type 2 NPI", or "Type 1 NPI". Matching is prioritized in this order. | Our approach is to resolve the entity name and address using the following waterfall:
|
| MatchedIDS | The identifier (TIN or NPI) of the organization, practice group, or provider that was resolved. | — |
| EIN | Will be a 9 digit un-hyphenated EIN or a 10 digit NPI number, each payer may use either format. EINs can be zero-led so this must be a text field. | — |
| PayerNPIList | A comma-separated list of 10 digit NPIs filtered by search criteria. | — |
| FilteredNPIListLength | Count of NPIs in PayerNPIList. Count may differ from PayerSourceNPIListLength due to zombie rate elimination (i.e., NPIs with identified zombie rates are removed). | — |
| PayerSourceNPIListLength | Count of distinct, unfiltered NPIs published by payers in the raw MRF data source for a given network_id, EIN, and code. | — |
| AllPayerIndividualNPIsS | Count of distinct credentialed type 1 (individual-provider) NPIs linked to the EIN for the selected network, with no filters applied. | For the selected network, we search all NPI lists to identify the total count of distinct type 1 (individual-provider) NPIs associated with an EIN |
| AllPayerGroupNPIsS | Count of distinct credentialed type 2 (organization-provider) NPIs linked to the EIN for the selected network, with no filters applied. | For the selected network, we search all NPI lists to identify the total count of distinct type 2 (organization-provider) NPIs associated with an EIN |
| MostCommonPayerNPITaxonomyS | An NUCC primary taxonomy code such as "207X00000X". | The most common NUCC primary taxonomy code for the NPIs in the npi_list field. The primary taxonomy for each NPI is obtained using NPPES.If a filter for "taxonomy" is set, then Signal will only return groups where the majority of the npi-list belongs to that taxonomy. |
| MostCommonPayerNPITaxonomyNameS | A description for the taxonomy such as "Orthopedic Surgery". | Tables from https://nucc.org/ |
| MostCommonPayerNPIRegionS | The state abbreviation (e.g., "TX", "CA"). | This is the most common state across all NPIs in the source npi_list from the MRF. The state for each NPI is obtained using NPPES.If a filter for "region" is set, then Signal will only return groups where the majority of the npi-list belongs to that region. |
| CBSAsS | The relevant CBSAs within the npi_region. | This will only be populated if a user selects CBSA filters within Signal. |
| EntityAddressS | The address of the organization, practice group, or provider that was resolved. | — |
| Billing Code | ||
| CodeS | The specific service being priced. | Normalized billing code to be zero-led and hyphens removed. MS-DRG will always be three characters, RC 4 characters, APR DRG 4 characters.Note: If a custom code has been cross-walked to another code by Serif Health (e.g., EMR3 > 99283), the cross-walked code will show up in this field. |
| CodeGroupS | A higher-level billing code group category (e.g., code 27447 maps to Surgery). | Code group categories defined using clinical service categories derived from claims data. |
| CodeSubgroupS | A more specific billing code group subcategory (e.g., code 27447 maps to Musculoskeletal System). | Code subgroup categories defined using clinical service subcategories derived from claims data. When a code qualifies for multiple subgroups under its group, all matching subgroups are concatenated alphabetically with a / separator, so a code can reflect multiple clinical contexts within a single parent group. |
| CodeTypeS | E.g., CPT, HCPCS, DRG, CSTM. | All caps is enforced. |
| CodeTypeVersion | Relevant schedule / year of release for "code_type". | New CPT codes release each year so values will be '2023', '2024', etc. DRG codes version up using a numeric system (e.g., V38, V41, etc.). |
| OriginalCode | The specific service being priced (as posted in the payer’s MRF). | This field will always represent the code found on the MRF whether or not it has been modified or crosswalked to another code in some way. |
| OriginalCodeType | E.g., CPT, HCPCS, DRG, CSTM. | This field will always represent the code found on the MRF whether or not it has been modified or crosswalked to another code in some way. |
| IsImputedS | Indicates whether the ‘code’ for the record has been imputed / crosswalked from the payer’s original posting. | If a ‘code’ has been imputed / crosswalked by Serif Health, this field will indicate ‘TRUE’. |
| ModifierList | Descriptions included here: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00003604. | The list values are sorted and a space is added after each comma between values. |
| BundledCodeList | Only relevant for bundled arrangements or capitated contracts. Contains full set of codes included in bundle or contract. | If a 'bundled' arrangement in the source JSON contains an array of sub-element 'bundled_codes' or a 'capitation' arrangement contains 'covered_services', we join the array of sub-element billing codes together into a comma separated list. See this link for more details. The list values are sorted and a space is added after each comma between values. |
| BillingClass | "Institutional" indicates facility fees and "professional" indicates clinician / doctor fees. | All lower case is enforced. |
| PlaceOfServiceList | CMS place of service codeset: https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets. | Extracted from 'service_code' or 'service_codes' (which can be a string or array) in source MRF. The list values are sorted and a space is added after each comma between values. |
| Rate & Arrangement | ||
| NegotiationType | For negotiated_type there are five allowable values: "negotiated", "derived", "fee schedule", "percentage", and "per diem". The value are defined as:
| All lower case is enforced. |
| Arrangement | An indication as to whether a reimbursement arrangement other than a standard fee-for-service model applies. Allowed values: "ffs", "bundle", or "capitation". | All lower case is enforced. |
| Expiration | The date on which the agreement for the negotiated rate ends. | In practice, this field is typically blank or set to a default value of 9999-12-31. |
| AdditionalInformation | If the payer posts any additional context on the rates, we include them here. | "Empty" and "NULL" string values are truncated to an empty string. |
| IsBillablePrimaryTaxonomyS | A tri-state (boolean true, false, or NULL) indication of whether this code is billable by the given provider's primary taxonomy. | Generated using a probabilistic claims analysis, evaluating which provider primary taxonomies bill this particular billing code in the real world. If any NPI in the list is allowed to bill the code, IsBillablePrimaryTaxonomy will be true. If no NPI bills the code, it will be false. If no taxonomy is available, or we have no claims data for this particular code or CodeType, the field will be null. |
| IsBillableSecondaryTaxonomyS | A tri-state (boolean true, false, or NULL) indication of whether this code is billable by the given provider's secondary taxonomy. | Generated using a probabilistic claims analysis, evaluating which provider secondary taxonomies bill this particular billing code in the real world. If any NPI in the list is allowed to bill the code, IsBillableSecondaryTaxonomy will be true. If no NPI bills the code, it will be false. If no taxonomy is available, or we have no claims data for this particular code or CodeType, the field will be null. |
| IsBillableClaimsS | True when the "PayerNPIList" contains any NPIs that were observed to have billed the code in Serif Health's claims data. Note that if the code_type is RC, MS-DRG, or CSTM-ALL, this will always be True | We use our claims database to verify whether the NPIs published by payers have billed the code for a listed reimbursement rate in practice. |
| ClaimsBilledChargedAmountS | The claims-observed provider billed charge amount. | — |
| MRFRate | The total reimbursement, inclusive of both the patient's and payer's share of cost (as indicated in the payer’s MRF). | Rate rows with price equal to zero, < 1 dollar, > 100000000, and scientific notation are dropped. |
| RateS | Total reimbursement after any calculations performed by Serif Health from the rate posted by the payer. | If no calculations are applied, this field will match ‘mrf_rate’. |
| ClaimsTranslatedPayerRateS | The payer percentage translated into a dollar amount using the claims-observed billed charge amount. | — |
| RateTierS | A tri-state (High, Mid, Low) indication of whether a rate is an MD (High), PhD/NP (Mid), or MA (Low) rate.Our system will only label the rate tier associated with the maximum npi-list-length.Aetna will often copy/paste the same NPI list for multiple rate tiers for a given code and billing class. This helper column aims to disambiguate Aetna rates for all 9 codes (CPT codes that start with a 9). Read more here about our Aetna rate tier feature. | A rate tier is only included if there's a presence of at least 2 out of 3 rates that follow the 100%-85%-75% rate ladder. Otherwise, the rate tier value is blank.Rate tier calculation:
|
| RateTierDescriptionS | A description of the rate tier as a % of the MD rate. | Description definition:
|
| Hospital Validation | ||
| HPTLocationIDS | The Serif Health hospital MRF identifier matched to the payer rate during payer-to-hospital MRF rate validation. This identifier varies with each unique MRF posting from a hospital. | — |
| HPTLocationTemplateIDS | The Serif Health hospital identifier for the matched hospital location during payer-to-hospital MRF rate validation. This is a persistent identifier that remains constant across different MRF postings for a hospital. | — |
| HPTIDS | The Serif Health hospital record identifier that can be used to identify the record used for the HPT comparison in Serif Health's hospital MRF data library. | — |
| HPTDollarS | The matched hospital negotiated dollar amount from hospital price transparency data. | Joined from Serif Health hospital MRF data as standard_charge_negotiated_dollar. |
| HPTPercentageS | The matched hospital negotiated percentage amount from hospital price transparency data. | Joined from Serif Health hospital MRF data as standard_charge_negotiated_percentage. |
| HPTChargeGrossS | The matched hospital gross charge from hospital price transparency data. | Joined from Serif Health hospital MRF data as standard_charge_gross. |
| HPTTranslateHospitalPercentageS | The hospital negotiated percentage translated into a dollar amount using the gross charge from the HPT record. | The negotiated percentage from the hospital MRF multiplied by the gross charge from the hospital MRF. |
| HPTTranslatePayerPercentageS | The payer allowed amount percentage translated into a dollar amount using the gross charge from the HPT record. | The allowed amount percentage from the payer MRF multiplied by the gross charge from the hospital MRF. |
| HPTComparisonDiffS | The relative absolute difference between the payer and hospital reimbursement (rate or percentage). | If the hospital rate is $100 and the payer-stated rate is $105, the hpt_comparison_diff will be 0.05 (absolute value of the ratio of the rates minus 1). |
| HPTComparisonConfidenceS | High, medium, or low based on HPTComparisonDiff | High: 0-5%Medium: 5-30%Low: 30+% difference |
| HPTComparisonTypeS | A text label describing how the payer and hospital values were compared. If the payer posted a percentage and the hospital posted a dollar value (or vice versa), the percentage would be translated using the gross charge on the HPT data for comparison.Possible values:
| — |
| Claims Validation | ||
| ClaimsVerifiedS | Whether the payer-posted dollar rate matched a claims-observed rate within tolerance. | True when the relative difference between the payer rate and claims rate (associated with the claims_rate_column) is within a 5% tolerance. Only for claims validation and not for billed charges. |
| ClaimsComparisonDiffS | The relative absolute difference between the payer and claims-observed rates. Null when there is no verified dollar-to-dollar claims match. | If the claims rate is $100 and the payer-stated rate is $105, the claims_comparison_diff will be 0.05 (absolute value of the ratio of the rates minus 1). Only for claims validation and not for billed charges. |
| ClaimsComparisonTypeS | A text label describing how the payer and claims values were compared. Possible values: Payer=Dollar|Claims=Dollar, Payer=Percent|Claims=Dollar. | — |
| ClaimsTotalCountS | The total claim count backing the matched claims observation. Null when there is no verified dollar-to-dollar claims match. | Only for claims validation and not for billed charges. |
| ClaimsRateColumnS | The claims rate column (e.g. plan_allowed_amount, plan_paid_amount) matched to the payer rate during payer-to-claims rate validation. Null when there is no verified dollar-to-dollar claims match. | — |
| Benchmarks | ||
| SourceGroupMaxRateS | The maximum rate within the same network_id, source_group_id (unique identifier of ein and original payer-published npi list), billing_class, and code. | — |
| IsSourceGroupMaxRateS | True when the row's rate equals source_group_max_rate; otherwise False. | — |
| PercentOfSourceGroupMaxRateS | The row's rate as a percentage of source_group_max_rate. It shows how close the row's rate is to the source_group_max_rate. | Rate divided by source_group_max_rate. |
| EinMaxRateS | The maximum rate within the same network_id, ein, billing_class, and code. | — |
| IsEinMaxRateS | True when the row's rate equals ein_max_rate; otherwise False. | — |
| PercentOfEinMaxRateS | The row's rate as a percentage of ein_max_rate. It shows how close the row's rate is to the ein_max_rate. | Rate divided by ein_max_rate. |
| IsMostNpisPerEinCodeS | True when the source_group_id (unique identifier of ein and source npi list) has the highest source_npi_list_length among rows with the same network_id, ein, billing_class, and code; otherwise False.In practice, it identifies the source group with the most NPIs for a network_id/ein/billing_class/code combination. | — |
| Baseline | ||
| BaselineS | The baseline rate for the given code, modifier, place of service, and billing class combination. | We update our baseline rate tables annually or quarterly by pulling the tables directly from CMS. |
| BaselineScheduleS | A string indicating the baseline schedule used to generate the baseline. | By default, Serif Health uses the fields in each row to select the most appropriate CMS baseline schedule. IPPS, OPPS, Lab, Drug ASP, Anesthesia, and ASC schedules are supported and display their national payment amount for the billing code. For PFS, a MAC is selected by mapping each NPI in the NPIList to a MAC; the most common MAC value is used to set the baseline. If a MAC cannot be mapped, the PFS national payment amount value is used. |
| RelativeToBaselineS | The ratio of the rate divided by the baseline. When the baseline is a CMS-dictated dollar payment amount, this column represents "percent of CMS" for the relevant baseline schedule. When the baseline is a weight, this column represents a "base rate" commonly used for negotiating inpatient or anesthesia pricing. | Decimal division of the rate by the baseline. If the baseline column is not populated for the given record, this column will be blank. |
| BaselineScheduleYearMonthS | Effective year-month of the CMS baseline (if applicable) | — |
| BaselineScheduleMACS | MAC locality of the CMS baseline (if applicable) | — |
| BaselineScheduleIsNonfacilityS | True/False on whether the CMS baseline is a non-facility rate or facility rate (if applicable) | — |
| BaselineScheduleCCNS | CCN of the CMS baseline (if applicable) | — |
| BaselineScheduleModifierS | Modifier of the CMS baseline (if applicable) | — |
| Anesthesia | ||
| AnesthesiaConversionFactorMethodologyS | Indicates which conversion factor methodology the payer uses to post anesthesia-specific rates.Potential methodologies include:
| If a methodology is present, this means Serif Health has been able to identify the methodology that a particular payer utilizes to post anesthesia-specific rates based on various machine learning models. |
| AnesthesiaBaseUnitsS | Indicates assumed anesthesia base units for the overall rate (between 0 - 30). | Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units) |
| AnesthesiaTimeUnitsS | Indicates assumed anesthesia time units for the overall rate (between 0 - 10). | Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units) |
| AnesthesiaConversionRateS | Indicates assumed anesthesia conversion rate for the overall rate (between 10 - 550). | Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units) |
| AnesthesiaEstimatedDollarAmountS | Indicates assumed overall rate for an anesthesia-related code. | Based on the following formula to calculate anesthesia rates:Rate = (Conversion Rate) * (Base Units + Time Units) |
See the data for yourself
Explore a sample dataset and see how pricing looks across payers, providers, and markets.