Payer Data Dictionary
Output Column (Italics indicates column added by Serif Health) |
Description | Methodology |
| payer | Full payer name, e.g. “Blue Cross Blue Shield of Alabama” | |
| network_region | 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 network_region. If ambiguous, we may use web searches or other sources to identify the network region. |
| network_name | 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 |
| network_year_month | 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. |
| date_accessed | The date the source MRF file was accessed (i.e. downloaded from the payer and converted) | |
| entity_name | 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. |
| matched_on | 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: 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. |
| matched_id | 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. | |
| npi_list | A comma-separated list of 10 digit NPIs. | |
| npi_list_length | Count of elements in "npi_list" | |
| npi_taxonomy | An NUCC primary taxonomy code such as "207X00000X". | If a filter for "taxonomy" is set, then Signal will only return groups where the majority of the npi-list belongs to that taxonomy. |
| npi_taxonomy_name | A description for the taxonomy such as "Orthopedic Surgery". | Tables from https://nucc.org/ |
| npi_region | The state abbreviation (e.g. "TX", "CA"). | If a filter for "region" is set, then Signal will only return groups where the majority of the npi-list belongs to that region. |
| entity_address | The address of the organization, practice group, or provider that was resolved. | |
| code | 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. |
| code_type | E.g., CPT, HCPCS, DRG, CSTM | All caps is enforced |
| code_type_version | 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.). |
| modifier_list | 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. |
| bundled_code_list | 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. |
| billing_class | "Institutional" indicates facility fees and "professional" indicates clinician / doctor fees. | All lower case is enforced |
| place_of_service_list | 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. |
| negotiation_type | 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. |
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. |
| additional_information | 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. |
| is_billable | A tri-state (boolean true, false, or NULL) indication of whether this code is billable by the given provider. | Generated using a probabilistic claims analysis, evaluating which provider taxonomies bill this particular billing code in the real world. If any NPI in the list is allowed to bill the code, is_billable 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 code_type, the field will be null. Both primary and secondary taxonomies are considered for every NPI when generating is_billable. |
| baseline_rate | 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. |
| baseline_group | A string indicating the baseline schedule used to generate the baseline_rate value. | 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 npi_list 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. |
| rate | The total reimbursement, inclusive of both the patient's and payer's share of cost | Rate rows with price equal to zero, < 1 dollar, > 100000000, and scientific notation are dropped. |
| relative_to_baseline | The ratio of the rate divided by the baseline. When the baseline_rate is a CMS-dictated dollar payment amount, this column represents "percent of CMS" for the relevant baseline_schedule. When the baseline_rate 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_rate. If the baseline_rate column is not populated for the given record, this column will be blank. |