Payer Contracts and Fee Schedules
This dataset provides a comprehensive view of payer contracts and fee schedules, detailing allowed amounts by CPT and DRG codes, reimbursement methods, contract terms, and payment rates. It enables precise reimbursement validation, contract management, and financial analysis for healthcare providers and payers, supporting compliance and operational efficiency.
Sample rows
preview · 8 of 100 rows · all 18 columns| contract_idstring | reimbursement_methodstring | allowed_amountfloat | is_activeboolean | payer_namestring | payer_idstring | contract_effective_datedate | contract_expiration_datedate | contract_statusstring | service_code_typestring | service_codestring | service_descriptionstring | unit_of_measurestring | capitation_amountfloat | case_rate_amountfloat | per_diem_amountfloat | contract_terms_summarystring | last_updateddatetime |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CON-BATCH1-0001 | fee-for-service | 75 | true | HealthFirst Insurance | PAYER-001 | 2022-01-01 | 2024-12-31 | active | CPT | 99213 | Office/outpatient visit, established patient | per-service | blank | blank | blank | Annual review, fee-for-service for outpatient visits. | 2024-05-01T13:45:32 |
| CON-BATCH1-0002 | case-rate | 13500 | false | BluePeak Health | PAYER-002 | 2021-07-15 | 2023-07-14 | expired | DRG | 470 | Major joint replacement or reattachment of lower extremity | per-case | blank | 13500 | blank | Full case rate for DRG 470 with annual cap. | 2023-07-15T09:12:44 |
| CON-BATCH1-0003 | capitation | 25 | true | CuraPlus | PAYER-003 | 2023-03-01 | blank | active | other | CAP123 | Monthly capitation for primary care services | per-member-per-month | 25 | blank | blank | Capitation paid monthly per member. | 2024-04-25T16:08:21 |
| CON-BATCH1-0004 | per-diem | 1200 | true | CentralCare Health | PAYER-004 | 2022-05-10 | 2025-05-09 | active | DRG | 194 | Heart failure & shock with major complications | per-diem | blank | blank | 1200 | Per diem rate for inpatient stays, reviewed annually. | 2024-05-06T11:24:10 |
| CON-BATCH1-0005 | fee-for-service | 160.5 | true | MediTrust | PAYER-005 | 2024-02-01 | 2025-01-31 | active | HCPCS | J3490 | Unclassified drugs | per-service | blank | blank | blank | Fee-for-service for approved drugs. | 2024-05-02T10:11:17 |
| CON-BATCH1-0006 | fee-for-service | 105 | true | HealthFirst Insurance | PAYER-001 | 2023-10-01 | 2024-09-30 | active | CPT | 99214 | Office/outpatient visit, established patient, moderate complexity | per-service | blank | blank | blank | Fee-for-service for outpatient procedures. | 2024-05-08T14:07:51 |
| CON-BATCH1-0007 | per-diem | 950 | false | BluePeak Health | PAYER-002 | 2022-12-01 | 2023-11-30 | expired | DRG | 291 | Heart failure and shock with complications | per-diem | blank | blank | 950 | Per diem for cardiac inpatient stays. | 2023-12-01T08:19:30 |
| CON-BATCH1-0008 | case-rate | 17850 | false | CuraPlus | PAYER-003 | 2021-09-01 | 2023-08-31 | expired | DRG | 560 | Respiratory system diagnosis with ventilator support | per-case | blank | 17850 | blank | Case rate for DRG 560, annual review. | 2023-09-01T15:14:59 |
| CON-BATCH1-0009 | capitation | 18.75 | true | CentralCare Health | PAYER-004 | 2022-06-01 | blank | active | other | CAP456 | Capitation for pediatric care | per-member-per-month | 18.75 | blank | blank | Capitation for pediatric members. | 2024-05-11T17:21:35 |
| CON-BATCH1-0010 | fee-for-service | 19 | false | MediTrust | PAYER-005 | 2022-03-01 | 2023-02-28 | expired | HCPCS | G0008 | Admin influenza virus vaccine | per-service | blank | blank | blank | Fee-for-service for vaccine admin. | 2023-03-01T11:28:39 |
| CON-BATCH1-0011 | fee-for-service | 120 | true | HealthFirst Insurance | PAYER-001 | 2024-01-01 | 2025-12-31 | active | CPT | 99385 | Initial preventive medicine, new patient | per-service | blank | blank | blank | Preventive service at contracted rate. | 2024-05-12T09:55:05 |
| CON-BATCH1-0012 | case-rate | 16500 | true | BluePeak Health | PAYER-002 | 2022-09-01 | 2024-08-31 | active | DRG | 872 | Septicemia with major complications | per-case | blank | 16500 | blank | Case rate for DRG 872, quarterly review. | 2024-05-09T16:57:23 |
| CON-BATCH1-0013 | capitation | 34.5 | true | CuraPlus | PAYER-003 | 2023-05-01 | blank | active | other | CAP789 | Monthly capitation for behavioral health | per-member-per-month | 34.5 | blank | blank | Behavioral health capitation. | 2024-05-13T13:32:18 |
| CON-BATCH1-0014 | per-diem | 800 | false | CentralCare Health | PAYER-004 | 2022-02-01 | 2023-01-31 | expired | DRG | 191 | Cardiac arrhythmia and conduction disorders | per-diem | blank | blank | 800 | Per diem for cardiac arrhythmia. | 2023-02-01T15:20:04 |
| CON-BATCH1-0015 | fee-for-service | 55.25 | true | MediTrust | PAYER-005 | 2023-07-01 | 2024-06-30 | active | CPT | 93000 | Electrocardiogram, routine ECG with interpretation | per-service | blank | blank | blank | Fee-for-service for ECGs. | 2024-05-05T18:09:37 |
| CON-BATCH1-0016 | fee-for-service | 18.5 | false | HealthFirst Insurance | PAYER-001 | 2021-12-01 | 2023-11-30 | expired | CPT | 90471 | Immunization administration | per-service | blank | blank | blank | Immunization fee-for-service. | 2023-12-01T10:36:48 |
| CON-BATCH1-0017 | case-rate | 9800 | true | BluePeak Health | PAYER-002 | 2023-02-01 | 2024-01-31 | active | DRG | 853 | Infectious diseases with complications | per-case | blank | 9800 | blank | Case rate for infectious diseases. | 2024-05-07T12:30:22 |
| CON-BATCH1-0018 | capitation | 29.5 | false | CuraPlus | PAYER-003 | 2022-07-01 | 2023-06-30 | expired | other | CAP222 | Monthly capitation for senior care | per-member-per-month | 29.5 | blank | blank | Senior care capitation. | 2023-07-01T09:14:48 |
| CON-BATCH1-0019 | per-diem | 650 | true | CentralCare Health | PAYER-004 | 2023-06-01 | 2024-05-31 | active | DRG | 302 | Kidney and urinary tract infections | per-diem | blank | blank | 650 | Per diem for renal inpatient stays. | 2024-05-10T15:49:31 |
| CON-BATCH1-0020 | fee-for-service | 210.75 | true | MediTrust | PAYER-005 | 2022-08-01 | 2024-07-31 | active | HCPCS | A0428 | Ambulance service, basic | per-service | blank | blank | blank | Ambulance services at negotiated rate. | 2024-04-29T13:44:23 |
What the 100 rows show
from the 100-row sampleCase-rate (reimbursement method) stands out: mean allowed_
- 69%is_
active = true - 145.3median allowed_
amount - 2contract statuses
- 4service code types
- 4unit of measures
- 17payers
Median 145.3, from 12.5 to 22,000.
- string 10
- float 4
- date 2
- datetime 1
- boolean 1
Columns
18 columns in four groups| column | type | description | example |
|---|---|---|---|
| Text 10 columns | |||
contract_id | string | Unique identifier for the payer contractunique | CON-BATCH1-0001 |
payer_name | string | Name of the insurance payer or health plan | HealthFirst Insurance |
payer_id | string | Unique identifier for the payer organization | PAYER-001 |
contract_status | string | Current status of the contractactive · expired · pending · terminated | active |
reimbursement_method | string | Type of reimbursement (e.g., fee-for-service, per diem, case rate, capitation)fee-for-service · per-diem · case-rate · capitation · other | fee-for-service |
service_code_type | string | Type of service code used (e.g., CPT, DRG, HCPCS)CPT · DRG · HCPCS · other | CPT |
service_code | string | Specific code for the service (e.g., CPT code, DRG code) | 99213 |
service_description | string | Description of the medical service or procedureoptional | Unclassified drugs |
unit_of_measure | string | Unit of measure for the allowed amount (e.g., per service, per diem, per case, per member per month)5 values | per-service |
contract_terms_summary | string | Summary of key contract terms and conditionsoptional | Senior care capitation. |
| Numbers 4 columns | |||
allowed_amount | float | Contracted allowed amount for the service code0 or more | 75 |
capitation_amount | float | Monthly capitation payment amount, if applicable0 or more · optional | 25 |
case_rate_amount | float | Case rate payment amount, if applicable0 or more · optional | 13500 |
per_diem_amount | float | Per diem payment amount, if applicable0 or more · optional | 1200 |
| Dates and times 3 columns | |||
contract_effective_date | date | Date the contract becomes effective | 2022-01-01 |
contract_expiration_date | date | Date the contract expiresoptional | 2024-12-31 |
last_updated | datetime | Timestamp of the last update to this contract record | 2024-05-01T13:45:32 |
| True or false 1 column | |||
is_active | boolean | Indicates if the contract is currently active | true |
Use it for
A healthcare dashboard
The is_
active rate, allowed_ amount by reimbursement_ method and a breakdown of payer_ name. Excel, Power BI or Tableau. Why do the 23 case-rate rows have a mean allowed_
amount of 10,196? A root-cause class exercise
Hand out the rows and one question. The answer is in the data, not in the brief.
- Contracts100CON-BATCH1-000175fee-for-…CON-BATCH1-000213500case-rateCON-BATCH1-000325capitati…
A software demo
Believable contracts with payer_
name, payer_ id and contract_ effective_ date to fill a screen in front of a buyer.
This dataset100 rows18 columns
Yours10,000 rows18 columns
blueprint · payer-contracts-and-fee-schedules
Behind this dataset
Same schema. As many rows as you need.
These 100 rows came out of a blueprint — 18 columns with generation rules behind each one. Open it in Data Factory to retune a column, add your own, wire in foreign keys, and run it at the size you actually need.
Rules it was built with
- Contract ID unique per payer agreement
- Payer name and TIN
- Contract effective date and termination date
- Fee schedule type: fee-for-service, per diem, case rate, capitation, DRG
- CPT code allowed amounts or percentage of charges
- DRG rates by MS-DRG code
- Per diem rates by level of care
- Carve-outs and special pricing
Open the blueprint in Data Factory
1 credit per row. New accounts start with 25 free credits.
- Exports
- CSV, JSON, JSONL, Parquet, SQL, Excel, TSV, XML
- Licence
- yours to use, including commercially
- API slug
- payer-contracts-and-fee-schedules