Every claim, routed to its Medicare payment system
Bill type and provider type decide which system a claim belongs to. Each one has a published CMS source for its grouping and its rate, and every one runs on the same pass. Ordered by dollars in a typical Medicare Advantage population.
Two systems are paid from a rate set for the individual provider and sent to it in a letter: rural health clinics and critical access hospitals. No CMS file publishes those rates. They are loaded as a table, and claims priced without one are flagged on the mart.
The priced claims mart
One row per claim: expected Medicare payment, what was paid, the difference and its reason.
Look up a claim
Pick a hospital outpatient claim. Left, the claim as it was submitted. Right, what the CMS programs did with it, line by line, and how that compares with what was paid.
Five synthetic claims, priced by the CMS I/OCE and OPPS pricer at a public provider. See every step for a claim like this.
One claim, traced
A synthetic claim followed to its price. Each step names the CMS program or file that performed it.
Look up a rate
Four public hospitals, with the factors the public provider file carries for them and what the CMS pricers pay them for common groups. Pick one.
The base rate is a lookup. The claim price is not: transfers, outliers and line packaging depend on the claim, which is why the engine runs on claims and not on a rate sheet.