Claim system check
An independent check on your claim system’s Medicare pricing.
Claims priced in NetworX, Facets Rate Manager, an Optum pricer or a homegrown engine can drift from Medicare: a missed rate file, a stale wage index, an outlier or transfer rule configured slightly wrong. Price the same claim here and see the difference, to the cent, with every step shown.
Why a second price
- Percent-of-Medicare contracts depend on it. When a contract pays 120% or 150% of Medicare, an error in the Medicare base carries straight into every payment.
- Rate loads go wrong quietly. Quarterly fee schedule updates, the October inpatient rate year, mid-year corrections and hospital-specific factors all have to land in the claim system on time.
- Appeals need the derivation. A provider dispute is settled faster when the payer can show each component: DRG weight, wage index, teaching and low-income add-ons, outlier and transfer math.
What you can check
- Inpatient (IPPS): a DRG calculator and Medicare repricing for any acute-care hospital, with MS-DRG regrouping from the codes. Inpatient (IPPS DRG) · MS-DRG grouper
- Outpatient (OPPS / APC): line-by-line hospital outpatient pricing with packaging and edits. Outpatient pricer
- Professional (837P): physician fee schedule pricing by place of service and locality. Professional claim pricer
- Skilled nursing and Medicaid: PDPM per diem and state APR-DRG methods. SNF claim · Medicaid
- Volume: batch repricing and an API for whole claim files. Batch repricing · API
How accurate it is
5,000 synthetic inpatient claims at 60 real hospitals were priced both here and on the CMS Web Pricer: all 5,000 within $1.00. Method and results on request.
Check 20 of your own claims, free
Send 20 lines your claim system has already priced, with names, member IDs and dates removed. Each comes back with our price, every step, and the step where your system and ours differ, flagged in both directions. Mutual NDA on request.
Questions
Is this affiliated with Optum, Cognizant or TriZetto?
No. cmswebpricer.com is an independent tool. NetworX, Facets and TriZetto are trademarks of Cognizant; Optum is a trademark of Optum, Inc. They are named only to say which systems’ output this check is built to compare against.
Does it replace my claim system’s pricer?
No. Your claim system still pays the claim. This is a second, independent price for the same claim so a payment-integrity, configuration or audit team can see whether the two agree and, if not, which component differs.
Which claim types can be checked?
Medicare inpatient (IPPS / MS-DRG), outpatient (OPPS / APC), professional claims on the physician fee schedule, skilled nursing (PDPM) and several state Medicaid APR-DRG methods.