1 of 100

Payerset Documentation

Payerset Resource Center

Documentation Overview

Our mission is to empower healthcare organizations, insurance carriers, researchers, consultants, and data-driven professionals with the most accurate and comprehensive healthcare price transparency data on the market. This resource center is aimed to customers to have an understanding of the data structures, payer & provider compliance with the CMS mandates, and how to use the Payerset platform.

If you have any questions or require further assistance, please reach out to . We are committed to delivering an exceptional experience and look forward to helping you unlock the true value of healthcare data for your organization.

Using The Payerset Platform

Guides

Payerset Rate Explorer Training & Onboarding Documentation

Welcome to the Payerset Rate Explorer™ Training and Onboarding section of our documentation! In this section, we highlight how the Rate Explorer portal works and will guide you through the initial steps to get started, helping you navigate the platform with ease. We also address common issues you might face using Price Transparency data, and we'll showcase how to create and analyze datasets.

Get started by clicking below or using the left-side panel.

Getting Started

Rate Explorer Overview

Payerset Rate Explorer is a tool designed to enhance health plan price transparency, offering access to comprehensive payer Machine Readable Files (MRF) data for analysis and comparison. Created to address the complexities and opacity of healthcare pricing, the portal enables users to easily navigate, understand, and benchmark healthcare pricing data across different payers and organizations. By providing clear, accessible, and actionable pricing insights, Rate Explorer supports informed decision-making in healthcare pricing and strategy.

The Payers we currently support are listed to the left under the PAYERS section of the documentation. Additionally, you can find information about the various fields that are available in the .

You can learn more about Rate Explorer at

Creating a Rate Comparison

Analysis Creation

Now onto the fun part, creating an analysis!

The Comparison Analysis tool allows you to select a series of billing codes, payers, and providers to compare rates across these dimensions.

You can create a Comparison Analysis in two ways:

Select "Create a Rate Comparison" from the main tile on the home page OR

Creating a Fee Schedule

Fee Schedule Creation

The Fee Schedule tool allows you to select a single NPI and payer to generate the full list of rates by billing code for that particular NPI and Payer.

Note: Fee Schedules only include rates where the Billing Code Modifier is either blank, 00, 26, or TC.

There are two ways to create a new Fee Schedule. You can use the "New analysis" button in the top-right corner of the Fee Schedule page or click on "Create Fee Schedule" from the home page. We'll create our first fee schedule from the home page.

Choose Date Snapshot

Similar to creating a Rate Comparison, you can also choose a date snapshot when creating Fee Schedule. The data will auto populate to the most recent available date. You can select an alternative snapshot date from the dropdown to view rates and gain insights to how they may have changed over time.

Stay tuned for further enhancements to utilizing these historical rates for advanced analysis and comparisons

Choose a Provider

Use the filters on the left-hand panel to narrow your search down to a single NPI. You can also utilize the search bar to search for specific NPIs in conjunction with the filters.

Payers

After selecting a provider, the next step in creating the Fee Schedule is to choose a single payer, which will allow you to generate the complete fee schedule. The list of available payers on this screen will automatically filter based on the NPI you selected previously, ensuring that there will be rate data for these payers.

Generate Your Fee Schedule

When you're ready, click "Generate Fee Schedule" and Payerset will crawl our data lake to pull all of the data you requested. This can take from a few seconds up to 10 minutes - fee schedules tend to take longer than typical comparisons because we are pulling all the rates for a given provider.

Once the analysis completes, you will see some KPIs detailing how many rates were found, as well as a visualization showing the distribution of those rates by billing code for each payer.

In the next section, we'll go over how to use this visualization, as well as the data details table and the exploration pivot table.

Analyzing your Data

Learn how to use the analysis tools in Payerset

Overview

Analyzing rate comparisons and fee schedules is the core function of Payerset, providing essential insights into healthcare pricing. Our platform offers three main analysis options: the Summary Page, Data Overview, and Explore screens. Each of these options provides unique perspectives and valuable insights into healthcare pricing data from high-level summaries to granular details.

Summary View

When your analysis is finished loading, you will land on the Summary screen, which shows you the total number of rates, providers, and services that apply to your selections and filters, as well as a distribution plot visualization of the data.

There are a few key features you can use on this screen to quickly compare rates across payers and providers.

Analysis Details & Metadata

You can see which payers, NPIs, and billing codes you have selected by hovering over the blue/green/purple chips at the top right of the page. If you have selected any data that does not contain rates (in the example below, you can see QualChoice does not have any data for the selected NPIs and billing codes), you will see an indicator that the data is Not Found.

Distribution Plot

The distribution plot shows how rates are distributed by payer across providers and billing codes, which enables you to get a quick idea of how disparate rates are across those payers for the same codes.

Rates can have different types, such as negotiated, fee schedule, per diem, or percentage. In the chart, you can toggle between dollars and percentages. As you can see below, VIVA Health provides both dollars and percentage rates, while the other payers show dollar values only.

Hover over a point on the chart to see the payer and provider details.

Filters

The filter options allow you to filter the data you are viewing by different dimensions so you can better compare apples-to-apples when looking at rates across codes, payers, and providers.

You can use either the "Add Filter" dropdown or "Toggle Filter Grid" as options for filtering. The Filter Grid option can provide a more detailed view of available filters.

To create a filter, select any combination of filters from either option.

To remove a filter, click the ⓧ in the box of the filter you want to remove.

You are always able to see your filters at the top of the screen so you can easily see what data you have filtered.

Filters will carry over from the Summary view to the Data and Explore views as well.

Data View

The data view is a comprehensive table of all the data available at the rate level.

The data view provides the most granular view of the data, so each record represents a single rate across all of the dimensions in the payer price transparency files.

Sorting & Filtering

To sort the table, click on the column you want to sort by. You can also search each column using the search boxes underneath the field name.

To add more columns, click the "More columns" button on the top right of the screen and you will be able to get a broader view of the data.

Export your current view by clicking the Export button.

Explore View

The explore view is a pivot table that enables you to aggregate the data by various different dimensions, as well as view multiple different metrics.

To start, choose a column and a measure.

You can also pivot the data horizontally by Payer, NPI, Organization Name, or Billing Code to get a better view of how data compares across dimensions.

Note that you may have to use the filters to get a good comparison of the data, and ensure that you're adding the proper columns so your comparisons are valid.

You are now ready to start digging in to all of the price transparency data within Payerset!

Hospital MRF - Standard Charges

Standard Charges - Hospital Price Transparency MRF Explorer.

Standard Charges MRF Explorer Overview (Hospital Data)

The Standard Charges rate analysis module is a powerful new feature of Payerset that enables users to gain comprehensive insights into the pricing structures of specific hospital systems. This tool is designed to provide a detailed view of rates for all services offered by a selected hospital, allowing for in-depth analysis and comparison.

Users can easily select a hospital system from an interactive map interface, making it simple to focus on specific geographic areas or institutions of interest.

All hospitals that are compliant are now added (over 4k!). We are continuously monitoring & adding Hospital MRF data () as they are published and verified from each individual system. Check back here often as we continue to build out new functionality and incorporate new data.

Please note that many of the hospitals use slightly different formats for their data and it could be missing or inaccurate, so please let us know at [email protected] if you see inaccuracies!

Nonstandard Codes

In some cases, negotiated rates in healthcare price transparency files use codes that fall outside the standard CPT, HCPCS, RC, or MS-DRG structures. These can represent carveouts or other situations where standard codes aren’t used. In the Payerset platform, these are referred to as nonstandard codes.

You can easily find and work with nonstandard codes in two places:

The Nonstandard Codes module
Any Fee Schedule you generate (nonstandard codes are always included by default)

Accessing and Using Nonstandard Codes in Payerset

Access the Nonstandard Codes Module

From the homepage, click the Nonstandard Codes menu item and select “Create an Analysis”.

First, use the filters on the left-hand panel along with the search bar to choose the Payers you want to include in this analysis.

Similarly, use the filters along with the search bar to choose the Payers to include in your final nonstandard code analysis. You can also name your analysis to refer back to or re-run to pull new data in the future.

Once you've set these parameters and clicked run your analysis, you can view the codes in two ways:

The Data tab for a quick overview of available codes and counts.
The Explore tab for deeper exploration and detailed analysis

For guidance on using the Explore tab, see our

Viewing Nonstandard Codes in Fee Schedules

Every Fee Schedule in Payerset automatically includes any nonstandard codes that appear in the source data. These codes are displayed alongside standard codes, ensuring you get a complete view of all available negotiated rates.No additional setup is required—nonstandard codes are included by default.

Within a Fee Schedule, you can identify nonstandard codes by the value “CSTM-ALL” within the “MRF Billing Code Type” field/filter.

Helpful Tips for Working with Nonstandard Codes

We have cleaned the data for ease of use and nonstandard codes show in the field “Billing Code” along with standard code. If you are looking at the files directly, this may not match.
Use the field “MRF Billing Code Name” to see the description of the nonstandard code

Hospital Transparency

Data Lake

Data Dictionary

Detailed descriptions of field names from Payer Price Transparency Machine-Readable files.

For pricing information, please see https://payerset.com/pricing

Please see below for various data dictionaries available for different types of payer and hospital data and metadata. For more information please reach out to [email protected]

Payer Transparency (TiC)Hospital Transparency Employer Reporting Plans EIN to NPI Map

Hospital Transparency

Data dictionary for the Hospital Price Transparency data for medical and pharmaceutical services. Below are the fields available for Data Lake customers.

Additional metadata for the hospital address can be made available but is not part of our standard offering.

Field Name

Description / Sample Values

Original Source

ADDITIONAL_PAYER_NOTES

Free-text notes hospitals sometimes include for a payer or plan. e.g., “Only applicable to self-pay patients seen in ER,” “BCBS rates exclude lab fees”

HOSPITAL MRF

BILLING_CLASS

Claim classification. “Institutional”, “Professional”

HOSPITAL MRF

Employer Reporting Plans

This dataset contains mappings of Payers and EIN values to the health plans they have (Reporting Plans) values based on the Transparency in Coverage data across our available payers.

Employer Reporting Plans Schema

Field Name

Field Type

Notes

NPI Data from NPPES

Data downloaded and stored for convenience, updated quarterly to ensure matching with the Payerset datasets

There are ~300 fields in this dataset, but the primary fields with their descriptions are listed below. All fields are available when you purchase any payer data.

The original dataset is available here from CMS:

Payerset also lightly transforms this data to provide Primary Taxonomy Code, using the switches in the dataset.

Here is a link directly to the NPPES download file:

Payer Transparency

AmeriHealth

This data contains the price transparency machine-readable files provided by AmeriHealth that have been normalized into easy-to-use tables.

AmeriHealth was not compliant in August 2025, their file links were broken. This has been rectified in September, which is the data the Payerset platform is displaying in the latest refresh.

Payerset Notes

Table of Contents

AvMed Health Pledge

This data contains the price transparency machine-readable files provided by Avmed Health Pledge that have been normalized into easy-to-use tables.

Group Health Cooperative of Eau Claire

This data contains the price transparency machine-readable files provided by Group Health Cooperative of Eau Claire that have been normalized into easy-to-use tables.

Payerset Notes

Table of Contents

HCSC

HCSC points to various Blues plans for their Price Transparency data and as a result does not have separate files themselves. Please reach out to [email protected] for more information.

Medicare Inpatient Methodology

Below outlines the Payerset methodology for calculating Medicare Inpatient rates.

Medicare Inpatient Prospective Payment System (IPPS) Fee Schedule Methodology

Document Information

Version: 1.0
Fiscal Year: FY 2026 (Discharges October 1, 2025 – September 30, 2026)
Last Updated: November 2025
Regulatory Authority: 42 CFR Part 412; CMS-1833-F (August 4, 2025)

Executive Summary

This document describes the methodology used to calculate estimated Medicare IPPS fee schedule amounts for acute care hospital inpatient stays. The calculations are based on the Centers for Medicare & Medicaid Services (CMS) FY 2026 IPPS Final Rule and associated data files. These estimates represent the expected base Medicare payment for a given hospital and MS-DRG combination, excluding outlier payments, new technology add-on payments, and certain other case-specific adjustments.

Regulatory Framework

Legal Authority

Medicare payments to acute care hospitals for inpatient stays are governed by Section 1886(d) of the Social Security Act, which establishes the Inpatient Prospective Payment System (IPPS). Under IPPS, hospitals receive a predetermined payment for each discharge based on the patient's diagnosis-related group (MS-DRG), adjusted for geographic and hospital-specific factors.

Primary Data Sources

Source

Description

Publication Date

Payment Components

IPPS payments consist of two separate components, each calculated independently:

Operating Payment: Covers the operating costs of providing inpatient care (labor, supplies, overhead)
Capital Payment: Covers capital-related costs (building depreciation, interest, rent, property taxes)

Total Estimated Payment

Operating Payment Calculation

Formula Structure

Step 1: Determine Adjusted Base Rate

The base rate varies depending on whether the hospital's wage index exceeds 1.0:

If Wage Index > 1.0 (Table 1A rates apply):

If Wage Index ≤ 1.0 (Table 1B rates apply):

Labor-Related Share

66% for hospitals with wage index > 1.0 (Table 1A)
62% for hospitals with wage index ≤ 1.0 (Table 1B)

This reflects CMS's rebasing of the IPPS market basket to a 2023 base year, as finalized in the FY 2026 IPPS Final Rule.

Cost of Living Adjustment (COLA)

Applies only to the nonlabor portion
Applicable only to hospitals in Alaska and Hawaii
Default value: 1.0 (no adjustment)

Step 2: Apply MS-DRG Weight

MS-DRG weights are published in Table 5 of the IPPS Final Rule and reflect the average resources required to treat patients in each diagnostic category relative to the average Medicare patient.

Note: Weights incorporate a 10% cap on year-over-year decreases, as mandated by regulation.

Step 3: Apply Quality Adjustments

Adjustment

Description

Application

These adjustments apply to the base operating DRG payment before DSH and IME add-ons.

Step 4: Apply DSH and IME Add-Ons

Disproportionate Share Hospital (DSH) Adjustment

The DSH adjustment compensates hospitals that serve a disproportionate share of low-income patients. Post-ACA (FY 2014+), hospitals receive:

25% of their pre-ACA DSH payment as an empirically justified operating add-on (case-mix adjusted)
75% as uncompensated care payments (not included in this per-discharge calculation)

Source: DSHPCT field from CMS Impact File

Indirect Medical Education (IME) Adjustment

Teaching hospitals receive additional payments to account for the higher indirect costs associated with residency training programs.

Formula:

Where:

r = Resident-to-Bed Ratio (from Impact File)
1.35 = Congressional multiplier (represents 5.5% increase per 10% increase in teaching intensity)
0.405 = Empirically estimated teaching cost coefficient

Capital Payment Calculation

Formula Structure

Components

Component

FY 2026 Value

Source

Geographic Adjustment Factor (GAF)

The GAF adjusts capital payments for geographic variation in capital costs. Unlike the operating wage index adjustment, the GAF is a single multiplicative factor published in the Impact File.

Capital IME Adjustment

The capital IME formula differs from the operating IME formula:

Where:

e = Euler's number (≈2.71828)
0.2822 = Empirically estimated capital teaching coefficient
RADC = Resident-to-Average Daily Census Ratio

RADC Calculation:

Key Assumptions and Limitations

Assumptions

Standard Discharge: Calculations assume a standard discharge without transfer, early discharge, or post-acute care transfer adjustments.
No Outlier Payments: Extremely high-cost cases may qualify for additional outlier payments not reflected in these estimates.
No New Technology Add-Ons: Cases involving qualifying new technologies may receive additional payments (NTAP) not included here.
Quality Program Participation

Limitations

Estimation vs. Actual Payment: These are estimated fee schedule amounts. Actual Medicare payments may vary due to:
- Outlier payments for high-cost cases
- Transfer payment adjustments
- New technology add-on payments

Data Quality Notes

Validation Approach

Calculated fee schedule amounts should be validated against:

CMS IPPS Web Pricer (https://webpricer.cms.gov/)
Actual Medicare payment data from claims
Hospital cost reports

Expected Variance

When comparing estimated fee schedule amounts to actual Medicare payments:

±5% variance is typical and expected
±10% variance may indicate outlier cases, transfers, or special circumstances
>10% variance warrants investigation

Data Refresh Frequency

This methodology should be updated annually upon publication of the IPPS Final Rule (typically August).

Glossary

Term

Definition

Regulatory References

42 CFR Part 412 – Prospective Payment Systems for Inpatient Hospital Services
Social Security Act §1886(d) – Payments to Hospitals for Inpatient Hospital Services
CMS-1833-F – FY 2026 IPPS/LTCH PPS Final Rule (89 FR 36536, August 4, 2025)
42 CFR §412.64 – Federal Rates for Inpatient Operating Costs

Contact and Support

For questions regarding CMS payment policy:

CMS IPPS website: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps
CMS Web Pricer: https://webpricer.cms.gov/

This documentation is provided for informational purposes. Users should verify calculations against official CMS sources and consult with qualified healthcare reimbursement professionals for specific payment determinations.

MRF Links by State

Below are the hospitals that are compliant, or compliant enough to normalize, with the latest mandates from CMS. We are continuously reviewing and adding files based on meeting updated standards.

Payerset Documentation

Payerset Resource Center

Using The Payerset Platform

Guides

Getting Started

Rate Explorer Overview

Creating a Rate Comparison

Analysis Creation

Creating a Fee Schedule

Fee Schedule Creation

Choose Date Snapshot

Choose a Provider

Payers

Generate Your Fee Schedule

Analyzing your Data

Overview

Summary View

Analysis Details & Metadata

Distribution Plot

Filters

Data View

Sorting & Filtering

Explore View

Hospital MRF - Standard Charges

Standard Charges MRF Explorer Overview (Hospital Data)

Nonstandard Codes

Accessing and Using Nonstandard Codes in Payerset

Access the Nonstandard Codes Module

Viewing Nonstandard Codes in Fee Schedules

Helpful Tips for Working with Nonstandard Codes

Hospital Transparency

Data Lake

Data Dictionary

Hospital Transparency

Employer Reporting Plans

Employer Reporting Plans Schema

NPI Data from NPPES

Payer Transparency

AmeriHealth

Payerset Notes

AvMed Health Pledge

Payerset Notes

Baylor Scott and White Health Plan

Payerset Notes

Blue Cross Blue Shield Minnesota

Payerset Notes

Blue Cross Blue Shield Montana

Payerset Notes

Blue Cross Blue Shield Tennessee

Payerset Notes

Capital Health Plan

Payerset Notes

Community Care of North Carolina

Payerset Notes

Group Health Cooperative of Eau Claire

Payerset Notes

HCSC

Data Dictionary

Guides

Hospital MRF - Standard Charges

Standard Charges MRF Explorer Overview (Hospital Data)

Getting Started

Rate Explorer Overview

Payerset Resource Center

Additional Information

Change Your Password

Password Reset

Additional Information

Nonstandard Codes

Accessing and Using Nonstandard Codes in Payerset

Access the Nonstandard Codes Module

Viewing Nonstandard Codes in Fee Schedules

Helpful Tips for Working with Nonstandard Codes

Creating a Fee Schedule

Fee Schedule Creation

Choose Date Snapshot

Choose a Provider

Payers

Generate Your Fee Schedule

Creating a Rate Comparison