Fee Schedule Engine

Ingest any fee schedule. Price any claim line. Audit every decision.

CHO’s fee schedule pipeline separates the update path from the claim-time pricing path. Fee schedules are loaded, validated, versioned, and stored independently. At claim time, the pricing engine resolves the correct schedule, applies modifier logic, and returns an allowed amount with full audit trail — in sub-millisecond time from Redis hot cache.

Fee Schedule Sources

The platform supports five source types, each with its own ingestion format and update cadence.

CMS MPFS (Medicare Physician Fee Schedule)

• Annual release (January) with quarterly updates
• RBRVS-based: Work RVU + Practice Expense RVU + Malpractice RVU × Conversion Factor
• Geographic Practice Cost Index (GPCI) adjustments per locality
• CHO auto-ingests CMS flat files on release

CMS OPPS / ASC (Outpatient Prospective Payment)

• APC-based rates with status indicators
• Annual update with mid-year corrections
• Facility vs non-facility differential

TX Medicaid Fee Schedules

• HHSC / TMHP published rates
• STAR, STAR+PLUS, CHIP program-specific schedules
• Rate notices and mid-cycle adjustments
• Critical for any Texas managed care organization

Contracted Provider Rates

• Per-diem, case rate, percentage of Medicare, UCR
• Loaded per provider agreement with effective/term dates
• Network tier awareness (in-network, out-of-network, tier 1/2/3)

Portal Manual Upload

• Blazor portal interface for CSV/Excel upload
• Custom plan-specific schedules
• Validation and preview before activation

Update Pipeline

The update pipeline moves fee schedule data through three stages before it is available for claim-time pricing.

1. Ingestion & Validation (FeeScheduleLoaderService)

• Format auto-detection (CMS flat file, CSV, Excel, FHIR)
• Schema validation against expected structure
• CPT/HCPCS code verification against TerminologyService
• Duplicate detection — prevent double-loading
• Rejected loads generate detailed error reports

2. Versioning & Effective Dating (FeeScheduleVersionStore)

• Every load creates an immutable version (e.g., v2026.Q1 → v2026.Q2)
• Future-dated schedules auto-activate on effective date
• No destructive updates — old versions retained indefinitely
• Rollback to any prior version without data loss
• Full audit trail: who loaded, when, what changed

3. Fee Schedule Repository

Index Dimension	Purpose
Line of Business	Isolate Medicare, Medicaid, Commercial schedules
Provider Type	Facility vs professional rate differentiation
Place of Service	Office, outpatient hospital, ASC, etc.
Modifier	Component-specific rates (26, TC, etc.)
Procedure Code	CPT/HCPCS code lookup
Network	In-network, out-of-network, tiered
Contract	Provider-specific negotiated rates
Geographic Region	GPCI locality, state, ZIP-based

MongoDB serves as the primary store with Redis hot cache. Cache warming occurs on version activation. Multi-tenant isolation ensures each health plan has its own schedule sets.

Claim-Time Pricing

When an 837 claim line arrives for adjudication, the pricing engine resolves the allowed amount through a defined resolution order, applies modifier and reduction logic, and returns a fully auditable result.

Resolution Order

1. Contracted rate — Exact match on provider + procedure + network
2. LOB-specific fee schedule — e.g., TX Medicaid STAR rate
3. Medicare MPFS fallback — Default floor

Pricing Logic

Rule	Description
Modifier application	–26 (professional), –TC (technical), –59 (distinct procedure), etc.
Multiple procedure reduction (MPPR)	Per CMS rules — highest-valued at 100%, subsequent at 50%/25%
Geographic GPCI adjustment	Work, PE, and MP GPCI components per provider locality
Bilateral procedure rules	150% of single rate for modifier 50
Assistant surgeon reduction	16% of primary surgeon allowed amount (modifiers 80, 81, 82)
Anesthesia pricing	Base units + time units × conversion factor

Output

Each pricing call returns:

• Allowed amount per claim line
• Fee schedule ID + version used for the determination
• Pricing methodology applied (contracted, LOB schedule, Medicare fallback)
• Full audit reference for downstream review
• Sub-millisecond response from Redis hot cache

Engine Interactions

The fee schedule engine is one step in the claims adjudication pipeline. Each engine is a separate class library invoked by the claims-service orchestrator in this sequence:

Order	Engine	Role
1	Claims Scrub	Edit checks, clean claim validation
2	NCCI Engine	Unbundling — must run before pricing
3	Fee Schedule Engine	Price the claim line
4	COB Engine	Primary/secondary payer split
5	Benefit Engine	Copay, coinsurance, covered amount
6	Accumulators	Deductible application, OOP tracking

Operating Mode Behavior

The fee schedule engine operates differently depending on the platform’s configured operating mode for the line of business.

Augment Mode

CHO prices the claim independently and passes the allowed amount to QNXT. Can be used as a validation/override check against QNXT’s native pricing, or as the authoritative price if QNXT pricing is disabled for the line of business.

Replace Mode

CHO pricing IS the adjudication price. The allowed amount flows directly into CHO’s claim record as the system-of-record determination.

Related Documentation