Claims Paid as a Percent of Medicare
What a health plan paid as a percent of Medicare.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Claim lines, one per line
- 2026-03-02, Alpha Clinic, 99214, 11, 180, 1 2026-03-02, Alpha Clinic, 71046, 11, 60, 1, 26 2026-03-05, City Hospital, DRG 470, 21, 25000, 1
- Medicare locality
- TX-18
Result: Example: what the plan allowed as a percent of what Medicare would pay in Houston, on 2 of 3 claim lines (1 left out).
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Claim lines, one per line: service date, provider, code, place of service, allowed amount, units, modifiers
- Medicare locality: state and locality number, as TX-18 (one of 109 physician fee schedule localities)
How this is calculated
Citation
Medicare physician fee schedule: RVUs, GPCIs and conversion factor (42 CFR 414.20-414.22), facility or nonfacility by place of service (Pub. 100-04, ch. 12, sec. 20.4.2); claims data a plan may obtain under the Consolidated Appropriations Act, 2021, div. BB, title II, sec. 201 (gag clauses). Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.