State Medicaid inpatient APR-DRG pricer and New York Medicaid rate codes

Independent pricing tool. Not affiliated with, endorsed by, or operated by CMS, any state Medicaid program, or any government agency. Estimates are not a claims determination.

Stay

Program

APR-DRG and hospital

Septicemia & Disseminated Infections
Severity of illness

Days the patient no longer needed acute care while awaiting placement. Paid at the hospital's ALC per diem on top of the case payment.

No stay inputs change the Texas base payment. It is the hospital's standard dollar amount × the APR-DRG weight. Outlier thresholds are shown for reference.

Stay facts. Colorado uses them for the transfer per diem, day outliers and the lower-of-charges cap. All optional.

Find a rate code

Category

What a rate code is

New York Medicaid pays many services by rate code: a 4-digit code on the institutional or managed-care claim (837I, UB-04 value-code field) that names the payment rate and method, instead of a HCPCS or CPT line on the practitioner fee schedule. This reference covers the rate codes behind HARP behavioral-health home and community-based services, mental-health clinic (MHOTRS) and FQHC services.

PaymentRate codes

Sample result for APR-DRG 720 at severity 3, saved from the pricing engine. Change the inputs and press Price to price your own.

    How the payment builds

    Step and factorAmount

    Same stay at each severity level

    Same APR-DRG and hospital; only the severity weight changes. Severity is assigned by the grouper from the documented diagnoses.

    Rate-code reference

    Rate codeServiceHCPCS · modifierUnitRate, downstate

    HARP HCBS rows show the downstate (New York City region) fee-schedule rate and the HCPCS × modifier crosswalk. Clinic (MHOTRS) and FQHC rows are rate-based (APG base × weight, or the PPS per-visit rate) and provider-specific, so they show the basis instead of a flat fee. Upstate fees differ. Verify with the payer before billing.

    NY provider lookup

    FQHC and RHC providers by NPI, hospitals by operating certificate, or anyone by name. Shows each provider's default rate: FQHC PPS per visit, or the hospital APR-DRG base.

    Searching by name

    ChecksBilling

    Market position

    Hospital and stay factors

    Method notes

      Who can bill HARP BH HCBS

      A two-step managed-care flow: the plan bills the state under the rate code; the designated provider bills the plan at the fee-schedule amount.

      1. RendersState-designated BH HCBS provider, contracted with the plan
      2. Bills the planHCPCS code + U1/U2 modifier at the HCBS fee-schedule amount
      3. Bills the stateHARP plan or HIV-SNP submits the rate code (7784–7807)
      • CPST rate code depends on who renders it: 7790 physician · 7791 NP or psychologist · 7792 RN, LMHC, LMFT, LCSW, LMSW · 7793 other allowable professions.
      • Provider: state-designated for the specific BH HCBS and contracted with the HARP plan or HIV-SNP.
      • Enrollee: HARP enrollees are adults 21+ with significant behavioral-health need; BH HCBS needs an eligibility assessment by a state-designated assessing entity (usually a Health Home care manager).

      Billing reference

      On-site modifier
      U1
      Off-site modifier
      U2
      Revenue codes
      0513 · 0520 · 0900 · 0914
      Rate codes per claim
      one
      HARP capitation
      7580
      HCBS admin supplement
      7581

      Verify current codes and fee-schedule amounts with the payer before billing.

      How Medicaid APR-DRG payment is calculated

      States that pay hospitals by APR-DRG multiply a relative weight for the DRG and its severity of illness (1 minor to 4 extreme) by a hospital or statewide base rate, then add state-specific pieces. New York adds teaching, capital, direct medical education and alternate-level-of-care days. Texas multiplies the hospital's standard dollar amount by the weight. Colorado applies transfer per diems, day outliers and a lower-of-charges cap.

      The severity strip prices all four levels for the same DRG and hospital, and the market card ranks the hospital against every other hospital in the state for that DRG. The New York rate-code reference lists HARP, clinic and FQHC codes with their units and rates.

      Questions

      Which states are covered?

      New York, Texas and Colorado inpatient APR-DRG, plus the New York Medicaid rate-code reference.

      What is severity of illness?

      The APR-DRG subclass from 1 (minor) to 4 (extreme). Each level has its own weight, so the same DRG pays differently by severity.

      Are these managed care rates?

      No. They are fee-for-service rates. Managed care plans set their own rates by contract, often as a percentage of these.