Payer Data Dictionary

Last updated: May 28, 2026

Output Column

(Bold indicates column added by Serif Health)

Description

Methodology

Payer

Full payer name (e.g., “Blue Cross Blue Shield of Alabama”).


NetworkRegion

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.

NetworkName

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.

NetworkYearMonth

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.

DateAccessed

The date the source MRF file was accessed (i.e., downloaded from the payer and converted).


EntityName

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.

MatchedOn

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.

MatchedID

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.


NPIList

A comma-separated list of 10 digit NPIs.


NPIListLength

Count of elements in "npi_list".


NPITaxonomy

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.

NPITaxonomyName

A description for the taxonomy such as "Orthopedic Surgery".

Tables from https://nucc.org/

NPIRegion

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.

CBSAs

The relevant CBSAs within the npi_region.

This will only be populated if a user selects CBSA filters within Signal.

EntityAddress

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.

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.

CodeType

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.

IsImputed

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.

NegotiationType

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.

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.

IsBillablePrimary-

Taxonomy

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.

IsBillableSecondary-

Taxonomy

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.

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.

Rate

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’.

Baseline

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.

BaselineSchedule

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.

RelativeToBaseline

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.

Anesthesia-

Conversion-

FactorMethodology

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

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.

AnesthesiaBaseUnits

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)

AnesthesiaTimeUnits

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)

Anesthesia-ConversionRate

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)

Anesthesia-

EstimatedDollar-

Amount

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)

RateTier

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:

  • High = 100% of MD rate (+/- 1.5%)

  • Mid = 85% of MD rate (+/- 1.5%)

  • Low: 75% of MD rate (+/- 1.5%)

RateTierDescription

A description of the rate tier as a % of the MD rate.

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%)

HPTID

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.

HPTDollar

The matched hospital negotiated dollar amount from hospital price transparency data.

Joined from Serif Health hospital MRF data as standard_charge_negotiated_dollar.

HPTComparisonType

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 vise 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

HPTComparisonDiff

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).

HPTChargeGross

The matched hospital gross charge from hospital price transparency data.

Joined from Serif Health hospital MRF data as standard_charge_gross.

HPTPercentage

The matched hospital negotiated percentage amount from hospital price transparency data.

Joined from Serif Health hospital MRF data as standard_charge_negotiated_percentage.

HPTTranslateHospitalPercentage

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.

HPTTranslatePayerPercentage

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.