API PROCESSING: In the interconnected world of health claim processing, pricing and editing may be only a part of a complex process. The CMSPricer API provides the pricing as a service. Your application can submit the request for pricing, and the API returns the results directly into your application. The API approach is most advantageous for the technically advanced client that can use REST API using JSON to take care of the Medicare pricing.
Step 1- Import from spreadsheet (CSV file)
Step 1- Create claim by importing your data from a spreadsheet or manual entry
Step 2- Review Claim
Step 3- Price Claim
Step 4- Export back to spreadsheet and download onto your laptop
Medicare PPS and EDITS
Medicare Perspective Payment Systems:
Medicare Institutional Data (CMS-1450/ UB-04 / ANSI 837i)
- Hospital acute inpatient (IPPS / MS-DRG)
- Hospital outpatient (OPPS)
- Ambulatory surgery center (ASC)
- Durable Medical Equipment (DME)
- End stage renal disease (ESRD with "composite" rates and OPPS/Fee Schedule)
- Skilled nursing facilities (SNF)
- Inpatient rehabilitation facilities (IRF)
- Inpatient psychiatric facility (IPF)
- Long term care hospital (LTCH)
- Outpatient rehabilitation facility (ORF)
- Critical access hospitals (CAH)
- Sole community hospitals (DRG plus an SCH "add on")
- Comprehensive outpatient rehabilitation facilities (CORF)
- Rural health clinic (RHC)
- Hospice, federally qualified health centers for IP and OP (FQHC)
- Community mental health centers (CMHC)
- Swing bed
- Ambulance
- Home health agency (HHA)
Medicare Professional Data (CMS-1500/ HCFA-1500 / ANSI 837p)
- Professional / physician (RBRVS) including all localities
- Parenteral and Enteral nutrition (PEN)
- Drugs
- Clinical labs
- Prosthetics, orthotics and surgical suppliers (POS)
Claim Edits
- Diagnosis Code Validation
- Local Coverage Determination (LCD)
- National Coverage Determination (NCD)
- Age Edits
- Gender Edits
- Outpatient Code Edits (IOCE)
- Medically Unlikely Edits (MUE)
- Correct Code Initiative (NCCI)
- CPT Edits
- RVU Edits
- Modifier Edits
- Advance Benefits Notice of Non-Coverage (ABN)