Medicaid Rate API

Programmatic access to Medicaid reimbursement rates across six states. Look up outpatient fee schedules, inpatient DRG payments, and provider data in real time.

Why the API

Automate

Build rate lookups into your everyday pricing workflows.

Scale

Batch-price hundreds of claims in one call. Most responses in under one second.

Integrate

RESTful JSON. Any language, any platform.

Getting Started

Request access

Fill out the form and we'll set up your account. Usually same-day.

Get your API key

We'll send you an API key. Evaluating? We offer trial keys on request.

Start querying

Hit the endpoints. Rates back in milliseconds.

Authentication

All requests need a Bearer token in the Authorization header. Keys are scoped to specific states; a request against a state not on your key returns 403 state_not_enabled. Don't have a key? Request access.

Base URL: https://api.staterates.health/api/v1

The key must go in the Authorization header, not the URL; we reject ?api_key=… with 400 api_key_in_query so keys never end up in access logs or browser history.

Follow best practices to keep your keys safe. Don't embed secret API keys in source code or client-side applications. Instead, use your server platform's secrets vault to provide keys to your server-side applications. If your platform doesn't offer a secrets vault, set your keys in environment variables.

Request

curl "https://api.staterates.health/api/v1/ca/outpatient/rate?billing_code=99213&npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Python

import os
import time
import requests

API_KEY = os.environ["STATERATES_API_KEY"]
URL = "https://api.staterates.health/api/v1/tx/inpatient/rate/batch"

def price_claims(claims, max_retries=5):
    headers = {"Authorization": f"Bearer {API_KEY}"}
    for attempt in range(max_retries):
        resp = requests.post(URL, headers=headers,
                             json={"requests": claims}, timeout=30)
        if resp.status_code == 429:
            time.sleep(2 ** attempt)   # 1s, 2s, 4s, 8s, 16s
            continue
        resp.raise_for_status()
        return resp.json()
    raise RuntimeError("rate-limited after all retries")

claims = [{
    "npi": "1831128974", "billing_code": "593-4", "soi": 4,
    "length_of_stay": 10, "discharge_date": "2026-03-01",
}]
print(price_claims(claims))

GET/ca/outpatient/rate

California Outpatient Rates

Look up a Medi-Cal outpatient rate by HCPCS code and provider. The returned rate reflects the applicable conversion factor, HOPD multiplier, and modifier adjustments.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	HCPCS procedure code (e.g., 99213).
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	OSHPD ID: California hospital identifier.
`provider_name`1 required	string	Provider name (partial match, min 2 characters). Returns rates for all matches.
`provider_type`	string	State Rates provider classification. Values: hospital, physician_office, surgical_clinic, free_clinic, podiatrist, nurse_anesthetist, other_clinic. If omitted, resolved from provider's taxonomy.
`procedure_type`	string	Medi-Cal procedure type. Values: Allied Health and other programs, Anesthesia, Assistant Surgeon, Diagnostic and Treatment (EPSDT), Early and Periodic Screening, Expanded Access to Primary Care (EAPC), Injection, Justice Involved, Local Educational Agency, Medi-Cal Waiver, Medicine, Multipurpose Senior Services Program (MSSP), Palliative Care, Pathology and Clinical Laboratory, Podiatrist, Primary Surgeon, Psychology Services for Mental Health Expansion, Radiology, Targeted Rate Increase, Vision Care. Valid values vary by billing code; if omitted, the most common type is selected automatically.
`service_type`	string	Medi-Cal service type. Values: ABORTION, ANESTHESIOLOGY, ANESTHESIOLOGY (OB), Family Planning Services, FIXED PRICE, GYN, INJECTIONS, MEDICINE, MEDICINE EMERGENCY, OB (C-SECTION), OB (VAGINAL DELIVERY), OTHER OB, OTHER SURGERY, PATHOLOGY, PODIATRY MEDICINE, PODIATRY PRIMARY CARE I & II - ADULT, PODIATRY PRIMARY CARE I & II - CHILD, PODIATRY RADIOLOGY, PODIATRY SURGERY, PRIMARY CARE I, PRIMARY CARE II - ADULT, PRIMARY CARE II - CHILD, RADIOLOGY, SURGERY FIXED PRICE, SURGERY (LAPAROSCOPY GYN), TUBAL STERILIZATIONS, WELL CHILD EXAMS. Valid values vary by procedure type; if omitted, selected automatically.
`child_patient`	boolean	True if patient is under 21 years of age. Defaults to false (adult).
`family_planning_primary_dx`	boolean	True if billed with a primary family planning diagnosis code. Adds 90.9% to the rate for qualifying E&M codes.
`emergency_room`	boolean	True to use ER pricing. ER rates use a higher conversion factor with no HOPD add-on or cutback.
`modifier`	string	HCPCS modifier. Values: 26 (Professional Component), TC (Technical Component).
`date_of_service`	string	Date of service (MM/DD/YYYY or YYYY-MM-DD). Defaults to today.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	OSHPD ID (hospitals) or Medi-Cal Provider Number (professionals).
`provider_name`	string	Provider name.
`provider_type`	string	State Rates provider classification used for rate lookup. Values: hospital, physician_office, surgical_clinic, free_clinic, podiatrist, nurse_anesthetist, other_clinic.
`provider_type_label`	string	Human-readable label for the State Rates provider classification (e.g., Hospital, Physician Office).
`cbsa_code`	string	Core Based Statistical Area code.
`cbsa_description`	string	CBSA area description.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system. Values: HCPCS, APR-DRG.
`billing_code_description`	string	Human-readable code description. Populated for HCPCS Level II codes (CMS-sourced); null for CPT (HCPCS Level I) and EAPG/APG codes, whose descriptions are licensed content.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`basic_rate`	decimal	Basic rate (unit value) from fee schedule.
`conversion_factor`	decimal	Conversion factor applied to basic rate.
`modifier`	string	HCPCS modifier applied (e.g., 26, TC).
`modifier_adjustment`	decimal	Modifier adjustment factor (e.g., 0.29 for 26, 0.71 for TC).
`cutback_ind`	integer	Cutback indicator (1 = 20% reduction applied to hospital/surgical clinic rates).
`hopd_multiplier`	float	Hospital Outpatient Department add-on multiplier (1.4344) when applied.
`family_planning_multiplier`	float	Family Planning add-on multiplier (1.909) when applied.
`emergency_room`	boolean	True if emergency room conversion factor was applied.
`procedure_type_used`	string	Procedure type used for pricing.
`service_type_used`	string	Service type used for pricing.
`is_default_selection`	boolean	True if the API auto-selected the procedure/service type because none was specified.
`available_procedure_types`	string[]	Other procedure types available for this code. Only present when defaults were used.
`available_service_types`	string[]	Other service types available for this code. Only present when defaults were used.
`is_manually_priced`	boolean	True if code has no fee schedule rate; payment determined per claim.
`date_of_service_used`	date	The date of service the rate was priced against, echoed from the request. When you omit date_of_service, this returns the server default (today), so the resolved date is always visible.
`child_patient_used`	boolean	Echo of child_patient. True when submitted as true; null otherwise.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/ca/outpatient/rate?\
  billing_code=99213&\
  npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "state_provider_id": "106380013",
    "provider_name": "COMMUNITY HOSPITAL",
    "provider_type": "hospital",
    "provider_type_label": "Hospital",
    "cbsa_code": "31084",
    "cbsa_description": "Los Angeles-Long Beach-Anaheim, CA",
    "billing_code": "99213",
    "billing_code_type": "HCPCS",
    "billing_code_description": null,
    "payment_rate": "75.50",
    "payment_rate_type": "fee_schedule",
    "calculation_method": "4.07 (Basic Rate) × 18.55 (Conversion Factor)",
    "basic_rate": "4.07",
    "conversion_factor": "18.55",
    "modifier": null,
    "modifier_adjustment": null,
    "cutback_ind": null,
    "hopd_multiplier": null,
    "family_planning_multiplier": null,
    "emergency_room": null,
    "procedure_type_used": "Medicine",
    "service_type_used": "PRIMARY CARE I",
    "is_default_selection": true,
    "available_procedure_types": [
      "Medicine",
      "Targeted Rate Increase"
    ],
    "available_service_types": [
      "PRIMARY CARE I",
      "PRIMARY CARE II - ADULT",
      "MEDICINE"
    ],
    "is_manually_priced": false,
    "date_of_service_used": "2026-08-01",
    "child_patient_used": null,
    "effective_start_date": "2025-01-01",
    "effective_end_date": null
  }
]

POST/ca/outpatient/rate/batch

Look up multiple rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "npi": "1234567890",
      "billing_code": "99213"
    },
    {
      "npi": "1234567890",
      "billing_code": "99214",
      "child_patient": true
    }
  ]
}

GET/ca/inpatient/rate

California Inpatient Claims

Look up a Medi-Cal APR-DRG inpatient payment rate, with adjustments for transfers, cost outliers, and interim claims. The admission date determines the effective rate period.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	APR-DRG code (e.g., 593-4 for DRG 593, SOI 4).
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	OSHPD ID: California hospital identifier.
`provider_name`1 required	string	Hospital name (partial match).
`admit_date`	string	Admission date (MM/DD/YYYY or YYYY-MM-DD). Defaults to today. California uses the admission date to determine which rate period applies.
`transfer_claim`	boolean	Transfer claim. Discharge status 02, 05, 63, 65, 66, 82, 85, 91, 93, or 94 (transferred to another facility).
`interim_claim`	boolean	Discharge status = 30 (interim claim). Uses per-diem calculation.
`child_patient`	boolean	True if patient is under 21 years of age. Defaults to false (adult).
`length_of_stay`	integer	Length of stay in days. If omitted, defaults to the national average LOS for this APR-DRG.
`total_charges`	decimal	Total charges from the claim. If omitted, charges are estimated for outlier calculations.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	OSHPD ID: California hospital identifier.
`provider_name`	string	Provider name.
`street_address`	string	Hospital street address.
`city`	string	Hospital city.
`zip_code`	string	Hospital ZIP code.
`county`	string	Hospital county.
`cbsa_code`	string	CBSA code.
`cbsa_description`	string	CBSA area description.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system: APR-DRG.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`apr_drg`	string	APR-DRG code.
`soi`	integer	Severity of Illness level (1–4).
`drg_base_rate`	decimal	Hospital-specific DRG base rate (wage-adjusted).
`payment_relative_weight`	float	Payment relative weight (casemix weight × policy adjustor).
`casemix_adjustment_factor`	float	Hospital casemix adjustment factor.
`policy_adjustor_used`	string	Policy adjustor letter used. Values: A, B, C, D (based on age and NICU status).
`policy_adjustor_value`	float	Policy adjustor numeric value.
`designated_nicu`	boolean	Whether the hospital is a designated NICU facility.
`estimated_cost`	decimal	Estimated cost (total_charges × cost_to_charge_ratio).
`drg_base_payment`	decimal	Base DRG payment before adjustments.
`transfer_adjustment_applied`	boolean	Whether transfer adjustment was applied.
`transfer_adjusted_amount`	decimal	Payment after transfer adjustment.
`outlier_adjustment_applied`	boolean	Whether cost outlier adjustment was applied.
`outlier_adjustment_amount`	decimal	Outlier adjustment amount.
`cost_to_charge_ratio`	float	Hospital cost-to-charge ratio.
`outlier_threshold`	float	Outlier threshold amount ($99,000).
`marginal_cost_percentage`	float	Marginal cost percentage applied to outlier excess (0.53).
`charge_cap_applied`	boolean	Whether payment was capped to total charges (lesser-of rule).
`is_interim_claim`	boolean	Whether calculated as an interim claim.
`interim_per_diem_amount`	float	Per diem rate for interim claim calculation.
`length_of_stay_used`	integer	Length of stay used in calculation.
`national_average_los`	decimal	National average LOS for this APR-DRG.
`total_charges_used`	decimal	Total charges used (actual or estimated).
`total_charges_source`	string	Whether charges were 'actual' or 'estimated'.
`admit_date_used`	date	The admit date the rate was priced against, echoed from the request. When you omit admit_date, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/ca/inpatient/rate?\
  billing_code=593-4&\
  npi=1234567890&\
  length_of_stay=10&\
  total_charges=150000" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "state_provider_id": "106194016",
    "provider_name": "CHILDRENS HOSPITAL LOS ANGELES",
    "street_address": "4650 SUNSET BLVD",
    "city": "LOS ANGELES",
    "zip_code": "90027",
    "county": "LOS ANGELES",
    "cbsa_code": "31084",
    "cbsa_description": "Los Angeles-Long Beach-Anaheim, CA",
    "billing_code": "593-4",
    "billing_code_type": "APR-DRG",
    "payment_rate": "194522.35",
    "payment_rate_type": "claim",
    "calculation_method": "standard_drg_payment",
    "apr_drg": "593",
    "soi": 4,
    "drg_base_rate": "8950.25",
    "payment_relative_weight": 20.506,
    "casemix_adjustment_factor": 1,
    "policy_adjustor_used": "A",
    "policy_adjustor_value": 1.0294,
    "designated_nicu": true,
    "estimated_cost": "216945.00",
    "drg_base_payment": "183492.50",
    "transfer_adjustment_applied": false,
    "transfer_adjusted_amount": null,
    "outlier_adjustment_applied": true,
    "outlier_adjustment_amount": "11029.85",
    "cost_to_charge_ratio": 0.445,
    "outlier_threshold": 99000,
    "marginal_cost_percentage": 0.53,
    "charge_cap_applied": false,
    "is_interim_claim": false,
    "interim_per_diem_amount": null,
    "length_of_stay_used": 10,
    "national_average_los": "24.80",
    "total_charges_used": "150000.00",
    "total_charges_source": "actual",
    "admit_date_used": "2026-08-01",
    "effective_start_date": "2025-07-01",
    "effective_end_date": null
  }
]

POST/ca/inpatient/rate/batch

Look up multiple CA inpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "593-4",
      "npi": "1234567890"
    },
    {
      "billing_code": "194-1",
      "npi": "9876543210",
      "length_of_stay": 5,
      "total_charges": "85000",
      "child_patient": true
    }
  ]
}

GET/ca/providers/search

California Provider Search

Search for California Medicaid providers by NPI, OSHPD ID, name, location, or taxonomy. Returns provider details with outpatient and inpatient rate availability.

Parameters

Name	Type	Description
`npi`	string	National Provider Identifier (10 digits).
`state_provider_id`	string	OSHPD ID or Medi-Cal Provider Number.
`provider_name`	string	Provider name (partial match, min 2 characters).
`city`	string	City (partial match).
`zip_code`	string	ZIP code (exact match).
`taxonomy`	string	Taxonomy code filter.
`provider_type`	string	State Rates provider classification. Values: hospital, physician_office, surgical_clinic, free_clinic, podiatrist, nurse_anesthetist, other_clinic.
`limit`	integer	Max results (default 100, max 1000).

Returns

Field	Type	Description
`providers`	array	List of matching providers.
↳`npi`	string	Provider NPI.
↳`state_provider_id`	string	OSHPD ID or Medi-Cal Provider Number.
↳`provider_name`	string	Provider name.
↳`provider_type`	string	State Rates provider classification.
↳`provider_type_label`	string	Human-readable label for the State Rates provider classification.
↳`entity_type`	string	Individual or Organization.
↳`primary_taxonomy`	string	Primary taxonomy code.
↳`city`	string	City.
↳`state`	string	State.
↳`zip_code`	string	ZIP code.
↳`street_address`	string	Street address.
↳`cbsa_code`	string	CBSA code.
↳`cbsa_description`	string	CBSA area description.
↳`op_rates`	boolean	Has outpatient rates.
↳`ip_rates`	boolean	Has inpatient rates.
`total_results`	integer	Total number of results found.
`limit_applied`	integer	Limit applied to results.

Request

curl "https://staterates.health/api/v1/ca/providers/search?\
  provider_name=community&\
  city=los+angeles" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

{
  "providers": [
    {
      "npi": "1234567890",
      "state_provider_id": "106380013",
      "provider_name": "COMMUNITY HOSPITAL OF LONG BEACH",
      "provider_type": "hospital",
      "provider_type_label": "Hospital",
      "entity_type": "Organization",
      "primary_taxonomy": "282N00000X",
      "city": "LONG BEACH",
      "state": "CA",
      "zip_code": "90806",
      "street_address": "1720 TERMINO AVE",
      "cbsa_code": "31084",
      "cbsa_description": "Los Angeles-Long Beach-Anaheim, CA",
      "op_rates": true,
      "ip_rates": true
    }
  ],
  "total_results": 1,
  "limit_applied": 100
}

GET/fl/outpatient/rate

Florida Outpatient Rates

Look up a Florida Medicaid outpatient rate. HCPCS are used for professional claims, sourced from fee schedules. Hospital outpatient claims use provider-specific EAPG rates for payment.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	HCPCS code (e.g., 99213) or EAPG code (e.g., 00002).
`billing_code_type`	string	Code type filter. Values: HCPCS, EAPG. If omitted, returns results for all matching types.
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	FL Provider Base ID.
`provider_name`1 required	string	Provider name (partial match). Returns rates for all matches.
`provider_type`	string	State Rates provider classification. Values: PRACTITIONER, HOSPITAL, INDEPENDENT_LAB, ASC.
`modifier`	string	Modifier for component selection. Values: 26 (Professional), TC (Technical).
`place_of_service`	string	Place of service. Values: facility, non_facility. Facility POS codes (19, 21, 22, 23, 24) use the facility rate. Defaults to non-facility.
`child_patient`	boolean	True if patient is under 21 years of age. Defaults to false (adult).
`date_of_service`	string	Date of service (MM/DD/YYYY or YYYY-MM-DD). Defaults to today.
`paf_*`	boolean	EAPG Payment Adjustor Flags (hospital only): paf_multiple_significant, paf_same_significant, paf_clinical_significant, paf_packaging, paf_repeat_ancillary, paf_bilateral, paf_terminated.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	FL Provider Base ID.
`provider_name`	string	Provider name.
`provider_type`	string	State Rates provider classification. Values: PRACTITIONER, HOSPITAL, INDEPENDENT_LAB, ASC.
`provider_type_label`	string	Human-readable label for the State Rates provider classification.
`fl_provider_type_code`	string	Florida's own 2-digit provider type code from source files (e.g., 25 = Physician M.D., 26 = Physician D.O., 35 = APRN, 62 = Physician Assistant).
`fl_provider_type_code_description`	string	Florida's description for the provider type code.
`fl_specialty_code`	string	Florida's own provider specialty code from source files (e.g., 01 = General Practice, 65 = Maternal Fetal Medicine).
`fl_specialty_description`	string	Florida's description for the specialty code.
`hospital_class`	string	Hospital category (EAPG only).
`street_address`	string	Provider street address.
`city`	string	Provider city.
`county`	string	Provider county.
`zip_code`	string	Provider ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system. Values: HCPCS, APR-DRG.
`billing_code_description`	string	Human-readable code description. Populated for HCPCS Level II codes (CMS-sourced); null for CPT (HCPCS Level I) and EAPG/APG codes, whose descriptions are licensed content.
`modifier`	string	Modifier applied (sourced from the matched rate row, not request input).
`modifier_adjustment`	decimal	Derived ratio for PCI/TCI rows (pci/fsi or tci/fsi); runtime multiplier for the MODIFIER_ADJUSTMENTS carve-out (50/52/53/54/55/56/62/80). NULL on base / state-modifier rows.
`place_of_service`	string	'non_facility' / 'facility' on PRACTITIONER rows where the source has the distinction; NULL on PCI/TCI / lab / EAPG rows.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`is_manually_priced`	boolean	True when Florida publishes 'By Report' instead of an amount. The code is covered, but payment is set case by case after medical review, so payment_rate is null and rate_found is false.
`prior_auth_required`	boolean	Prior authorization required.
`specialty_multiplier`	float	Specialty-based rate multiplier.
`age_multiplier_applied`	decimal	Age multiplier if applied.
`provider_type_multiplier_applied`	decimal	Provider type multiplier (0.80 for APRN/PA).
`eapg_weight`	decimal	EAPG relative weight (hospital only).
`eapg_base_rate`	decimal	Hospital-specific EAPG base rate.
`eapg_policy_adjustor`	decimal	Hospital policy adjustor.
`eapg_childrens_addon`	decimal	Children's hospital add-on.
`paf_multiple_significant`	decimal	PAF: Multiple Significant Procedures adjustment.
`paf_same_significant`	decimal	PAF: Same Significant Procedure adjustment.
`paf_clinical_significant`	decimal	PAF: Clinical Significant Procedure adjustment.
`paf_packaging`	decimal	PAF: Packaging adjustment.
`paf_repeat_ancillary`	decimal	PAF: Repeat Ancillary adjustment.
`paf_bilateral`	decimal	PAF: Bilateral adjustment.
`paf_terminated`	decimal	PAF: Terminated Procedure adjustment.
`paf_adjustment`	decimal	Combined PAF adjustment factor (product of selected flags).
`date_of_service_used`	date	The date of service the rate was priced against, echoed from the request. When you omit date_of_service, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/fl/outpatient/rate?\
  billing_code=99213&\
  npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "state_provider_id": null,
    "provider_name": "FLORIDA MEDICAL GROUP",
    "provider_type": "PRACTITIONER",
    "provider_type_label": "Practitioner",
    "fl_provider_type_code": "17",
    "fl_provider_type_code_description": "Physician",
    "fl_specialty_code": "01",
    "fl_specialty_description": "General Practice",
    "hospital_class": null,
    "street_address": "100 MAIN ST",
    "city": "MIAMI",
    "county": "MIAMI-DADE",
    "zip_code": "33101",
    "billing_code": "99213",
    "billing_code_type": "HCPCS",
    "billing_code_description": null,
    "modifier": null,
    "modifier_adjustment": null,
    "place_of_service": "non_facility",
    "payment_rate": "47.41",
    "payment_rate_type": "fee_schedule",
    "calculation_method": "$47.41 (Practitioner Fee Schedule, Non-Facility) = $47.41",
    "prior_auth_required": false,
    "specialty_multiplier": null,
    "age_multiplier_applied": null,
    "provider_type_multiplier_applied": null,
    "eapg_weight": null,
    "eapg_base_rate": null,
    "eapg_policy_adjustor": null,
    "eapg_childrens_addon": null,
    "paf_multiple_significant": null,
    "paf_same_significant": null,
    "paf_clinical_significant": null,
    "paf_packaging": null,
    "paf_repeat_ancillary": null,
    "paf_bilateral": null,
    "paf_terminated": null,
    "paf_adjustment": null,
    "date_of_service_used": "2026-08-01",
    "effective_start_date": "2024-07-01",
    "effective_end_date": null
  }
]

POST/fl/outpatient/rate/batch

Look up multiple FL outpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "99213",
      "npi": "1234567890"
    },
    {
      "billing_code": "99214",
      "npi": "1234567890",
      "child_patient": true
    }
  ]
}

GET/fl/inpatient/rate

Florida Inpatient Claims

Look up a Florida Medicaid APR-DRG inpatient payment rate. Incorporates service, age, and provider adjustors, plus a children's hospital add-on. The discharge date determines the effective rate period.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	APR-DRG code (e.g., 140 or 140-2).
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	FL Provider Base ID.
`provider_name`1 required	string	Hospital name (partial match).
`discharge_date`	string	Discharge date (MM/DD/YYYY or YYYY-MM-DD). Defaults to today. Florida uses the discharge date (not admission date) to determine which rate period applies.
`transfer_claim`	boolean	Transfer claim. Discharge status 02, 05, 65, 66, 82, 85, 93, or 94 (transferred to another acute-care hospital).
`child_patient`	boolean	True if patient is under 21 years of age. Defaults to false (adult).
`length_of_stay`	integer	Length of stay in days. Defaults to average LOS.
`total_charges`	decimal	Total charges for outlier calc and charge cap.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	FL Provider Base ID.
`provider_name`	string	Provider name.
`hospital_class`	string	Provider category. Values: All Other, Rural, LTAC, Childrens, Teaching.
`trauma_class`	string	Trauma designation. Values: Level I, Level II, Pediatric. Null if not a trauma center.
`street_address`	string	Hospital street address.
`city`	string	Hospital city.
`county`	string	Hospital county.
`zip_code`	string	Hospital ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system: APR-DRG.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`apr_drg_code`	string	Base DRG code.
`soi`	integer	Severity of Illness (1–4).
`fl_relative_weight`	decimal	Florida-specific DRG weight.
`mean_los`	decimal	Average length of stay for this DRG.
`service_adjustor`	decimal	Service adjustor (1.0 or 1.3 for neonatal).
`age_adjustor`	decimal	Age adjustor (applied when age < 21).
`pediatric_service_line`	string	Pediatric service line classification.
`adult_service_line`	string	Adult service line classification.
`provider_adjustor`	decimal	Provider category adjustor.
`max_adjustor_used`	decimal	MAX(service, age, provider) adjustor used.
`statewide_base_rate`	decimal	FL statewide base rate.
`base_payment`	decimal	Base payment: base_rate × weight × max_adjustor.
`trauma_enhancement_amount`	decimal	Trauma enhancement amount.
`childrens_addon`	decimal	Children's hospital add-on (source value).
`childrens_addon_amount`	decimal	Actual children's add-on calculated.
`transfer_adjustment_applied`	boolean	Whether transfer adjustment was applied.
`transfer_adjusted_amount`	decimal	Payment after transfer adjustment.
`outlier_adjustment_applied`	boolean	Whether cost outlier was applied.
`outlier_amount`	decimal	Cost outlier adjustment amount.
`outlier_threshold`	float	Cost outlier threshold ($60,000).
`marginal_cost_pct`	float	Marginal cost percentage (0.60 or 0.80).
`charge_cap_applied`	boolean	Whether payment was capped at total charges.
`cost_to_charge_ratio`	decimal	Hospital CCR for outlier calc.
`casemix`	decimal	Hospital casemix index.
`length_of_stay_used`	integer	LOS used in calculation.
`total_charges_used`	decimal	Total charges used.
`discharge_date_used`	date	The discharge date the rate was priced against, echoed from the request. When you omit discharge_date, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/fl/inpatient/rate?\
  billing_code=140-2&\
  npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "state_provider_id": "100001",
    "provider_name": "FLORIDA GENERAL HOSPITAL",
    "hospital_class": "All Other",
    "trauma_class": null,
    "street_address": "500 HOSPITAL DR",
    "city": "JACKSONVILLE",
    "county": "DUVAL",
    "zip_code": "32209",
    "billing_code": "140-2",
    "billing_code_type": "APR-DRG",
    "payment_rate": "6850.75",
    "payment_rate_type": "claim",
    "calculation_method": "6210.50 (Base Rate) × 0.8500 (FL Weight) × 1.3000 (MAX Adjustor)",
    "apr_drg_code": "140",
    "soi": 2,
    "fl_relative_weight": "0.8500",
    "mean_los": "3.50",
    "service_adjustor": "1.0000",
    "age_adjustor": null,
    "pediatric_service_line": null,
    "adult_service_line": "Pulmonary",
    "provider_adjustor": "1.3000",
    "max_adjustor_used": "1.3000",
    "statewide_base_rate": "6210.50",
    "base_payment": "6850.75",
    "trauma_enhancement_amount": null,
    "childrens_addon": null,
    "childrens_addon_amount": null,
    "transfer_adjustment_applied": false,
    "transfer_adjusted_amount": null,
    "outlier_adjustment_applied": false,
    "outlier_amount": null,
    "outlier_threshold": 60000,
    "marginal_cost_pct": 0.6,
    "charge_cap_applied": false,
    "cost_to_charge_ratio": "0.3500",
    "casemix": "1.2500",
    "length_of_stay_used": 4,
    "total_charges_used": null,
    "discharge_date_used": "2026-08-01",
    "effective_start_date": "2024-07-01",
    "effective_end_date": null
  }
]

POST/fl/inpatient/rate/batch

Look up multiple FL inpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "140-2",
      "npi": "1234567890"
    },
    {
      "billing_code": "640-1",
      "npi": "9876543210",
      "length_of_stay": 3,
      "total_charges": "45000"
    }
  ]
}

GET/fl/providers/search

Florida Provider Search

Search for Florida Medicaid providers by NPI, Provider Base ID, name, or location. Returns provider details with FL-specific specialty codes and rate availability.

Parameters

Name	Type	Description
`npi`	string	National Provider Identifier (10 digits).
`state_provider_id`	string	FL Provider Base ID.
`provider_name`	string	Provider name (partial match).
`city`	string	City (partial match).
`county`	string	County (partial match).
`taxonomy`	string	Taxonomy code filter.
`provider_type`	string	State Rates provider classification. Values: PRACTITIONER, HOSPITAL, INDEPENDENT_LAB, ASC.
`limit`	integer	Max results (default 100, max 1000).

Returns

Field	Type	Description
`providers`	array	List of matching providers.
↳`npi`	string	Provider NPI.
↳`state_provider_id`	string	FL Provider Base ID.
↳`provider_name`	string	Provider name.
↳`provider_type`	string	State Rates provider classification. Values: PRACTITIONER, HOSPITAL, INDEPENDENT_LAB, ASC.
↳`provider_type_label`	string	Human-readable label for the State Rates provider classification.
↳`entity_type`	string	Individual or Organization.
↳`primary_taxonomy`	string	Primary taxonomy code.
↳`street_address`	string	Street address.
↳`city`	string	City.
↳`state`	string	State.
↳`zip_code`	string	ZIP code.
↳`county`	string	County.
↳`provider_category`	string	FL provider category.
↳`op_rates`	boolean	Has outpatient rates.
↳`ip_rates`	boolean	Has inpatient rates.
`total_results`	integer	Total results found.
`limit_applied`	integer	Limit applied.

Request

curl "https://staterates.health/api/v1/fl/providers/search?\
  provider_name=jackson&\
  city=miami" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

{
  "providers": [
    {
      "npi": "1234567890",
      "state_provider_id": "100001",
      "provider_name": "JACKSON MEMORIAL HOSPITAL",
      "provider_type": "HOSPITAL",
      "provider_type_label": "Hospital",
      "entity_type": "Organization",
      "primary_taxonomy": "282N00000X",
      "street_address": "1611 NW 12TH AVE",
      "city": "MIAMI",
      "state": "FL",
      "zip_code": "33136",
      "county": "MIAMI-DADE",
      "provider_category": "All Other",
      "op_rates": true,
      "ip_rates": true
    }
  ],
  "total_results": 1,
  "limit_applied": 100
}

GET/ny/outpatient/rate

New York Outpatient Rates

Look up a NY Medicaid outpatient rate. Methodologies are routed by provider type: Hospital, D&TC, and ASC APGs, as well as eMedNY Physician and Lab fee schedules.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	HCPCS code (e.g., 99213) or APG code.
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	NY Medicaid Provider ID (MMIS, 8-digit). NY's state-issued billing identifier (universal across professionals and hospitals).
`opcert`1 required	string	Hospital-only NY operating certificate. Not all NY providers have one.
`provider_name`1 required	string	Provider name (partial match, case-insensitive).
`provider_type`	string	NY provider type filter. Values: HOSPITAL, PHYSICIAN, OUTPATIENT_CLINIC_ASC, LABORATORY. If omitted, returns rates across all matching provider types.
`rate_code`	string	NY 4-digit rate code from UB-04 Value Code 24. HOSPITAL APG: 1400 → OPD visit, 1402 → ED, 1432 → OPD episode. OUTPATIENT_CLINIC_ASC: 1407 / 1422 → D&TC Clinic, 1408 → Amb Surg. If omitted, hospital APG defaults to OPD visit; D&TC/ASC defaults to the NPI's peer-group preferred column (Clinic over Amb Surg).
`service_region`	string	D&TC/ASC only. Values: Downstate, Upstate. Disambiguates the ~6 multi-region D&TC providers; auto-detected from provider address otherwise.
`modifier`	string	Modifier (PHYSICIAN HCPCS only). Values: 26 (Professional Component), TC (Technical Component). NY pre-multiplies at the data layer; modifier_adjustment carries the multiplier.
`place_of_service`	string	Place of service (PHYSICIAN HCPCS only). Values: facility, non_facility. If omitted, returns the source default row (typically non_facility).
`date_of_service`	string	Date of service (MM/DD/YYYY or YYYY-MM-DD). Selects the fee schedule (HCPCS) or APG weight version (APG codes) in effect on this date. Defaults to today.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	NY Medicaid Provider ID (MMIS, 8-digit).
`opcert`	string	NY Operating Certificate number. NULL for non-hospitals.
`provider_name`	string	Provider name.
`provider_type`	string	NY provider type. Values: HOSPITAL, PHYSICIAN, OUTPATIENT_CLINIC_ASC, LABORATORY.
`provider_type_label`	string	Human-readable provider type.
`ny_profession_or_service`	string	NY-published profession/service category (comma-delimited title case where a provider operates under multiple categories). Examples: Physician, Nurse Practitioner, Outpatient Clinic. NULL for some hospital rows.
`ny_provider_specialty`	string	NY-published specialty sub-classification (comma-delimited title case). Examples: Cardiology, Geriatric Medicine, General Dentistry.
`primary_taxonomy_code`	string	NPPES primary taxonomy code (NUCC standard).
`primary_taxonomy_display_name`	string	NPPES primary taxonomy display name (NUCC-enriched).
`street_address`	string	Provider street address.
`city`	string	Provider city.
`county`	string	Provider county.
`state`	string	Provider state (typically 'NY').
`zip_code`	string	Provider ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system. Values: HCPCS, APR-DRG.
`billing_code_description`	string	Human-readable code description. Populated for HCPCS Level II codes (CMS-sourced); null for CPT (HCPCS Level I) and EAPG/APG codes, whose descriptions are licensed content.
`rate_code`	string	NY 4-digit rate code echoed from request.
`modifier`	string	Modifier applied (e.g., 26, TC).
`modifier_adjustment`	decimal	Multiplier applied to base rate (PHYSICIAN modifier 26 / TC rows where NY pre-multiplies).
`place_of_service`	string	Place of service used.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`apg_weight`	decimal	APG relative weight (Solventum 3M v3.17, NY-branded as APG).
`px_based_weight`	decimal	HCPCS procedure-overlay weight (OT/PT/SLP/nutrition codes).
`apg_base_rate_used`	decimal	APG base rate applied (Hospital APG path or D&TC/ASC peer-group rate).
`apg_base_rate_source_column`	string	Which base-rate column was used. Hospital values: apg_base_rate_opd_visit, apg_base_rate_ed, apg_base_rate_opd_episode. D&TC/ASC values: apg_base_rate_dtc_clinic_{upstate\|downstate}, apg_base_rate_dtc_ambsurg_{upstate\|downstate}.
`payment_operating`	decimal	Operating portion of payment_rate (apg_weight × apg_base_rate_used). D&TC/ASC + Hospital APG paths.
`payment_capital`	decimal	Capital add-on per visit (D&TC/ASC only; per-NPI, ~$27 average). Hospital APG capital is bundled into the base rate.
`capital_anomaly`	boolean	TRUE when the NPI's published capital add-on falls outside the expected range; surfaces data-quality outliers for review.
`units_limit`	decimal	Per-claim units limit (when published).
`anesthesia_base_units`	decimal	Anesthesia base unit count for the code. NY publishes base units but no per-unit conversion factor; anesthesia rates are not computed (rate_found=false). Surfaced for downstream pricing.
`is_manually_priced`	boolean	TRUE for 'By Report' sentinel codes (payment_rate=NULL with explanatory message).
`prior_auth_required`	boolean	TRUE when the code requires prior authorization.
`date_of_service_used`	date	The date of service the rate was priced against, echoed from the request. When you omit date_of_service, this returns the server default (today), so the resolved date is always visible.
`service_region_used`	string	The region used to select the APG base rate (Downstate or Upstate), derived from the rate column actually priced (multi-region NPIs default to Downstate when the region is omitted). Null when region does not apply (hospitals, fee-schedule rows).
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/ny/outpatient/rate?\
  billing_code=99213&\
  npi=1407957863" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1407957863",
    "state_provider_id": "01234567",
    "opcert": null,
    "provider_name": "HAQ INAM UL",
    "provider_type": "PHYSICIAN",
    "provider_type_label": "Physician",
    "ny_profession_or_service": "PHYSICIAN",
    "ny_provider_specialty": "FAMILY PRACTICE",
    "city": "BROOKLYN",
    "county": "KINGS",
    "state": "NY",
    "zip_code": "11201",
    "billing_code": "99213",
    "billing_code_type": "HCPCS",
    "billing_code_description": null,
    "rate_code": null,
    "modifier": null,
    "modifier_adjustment": null,
    "place_of_service": "non_facility",
    "payment_rate": "86.75",
    "payment_rate_type": "fee_schedule",
    "calculation_method": "eMedNY Physician Fee Schedule (Non-Facility): $86.75",
    "apg_weight": null,
    "apg_base_rate_used": null,
    "apg_base_rate_source_column": null,
    "anesthesia_base_units": null,
    "is_manually_priced": false,
    "prior_auth_required": false,
    "date_of_service_used": "2026-08-01",
    "service_region_used": null,
    "effective_start_date": "2024-01-01",
    "effective_end_date": null
  }
]

POST/ny/outpatient/rate/batch

Look up multiple NY outpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "99213",
      "npi": "1407957863"
    },
    {
      "billing_code": "76700",
      "npi": "1407957863",
      "modifier": "26"
    },
    {
      "billing_code": "80048",
      "npi": "1629737200"
    }
  ]
}

GET/ny/inpatient/rate

New York Inpatient Claims

Look up a NY Medicaid inpatient rate. Pricing is routed by service type: acute care via APR-DRG, exempt psychiatric on a per-diem with age, intellectual-disability, and comorbidity factors, and six per-diem categories (Medical Rehab, CAH, Chemical Dependency Rehab, Adult and Child Dual Diagnosis, and Specialty Acute). Payer class (FFS or Managed Medicaid) selects the rate schedule.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	APR-DRG code (e.g. '140', '140-2'). Required for acute and psychiatric service types; optional for per-diem service types (CAH, med_rehab, etc.) where pricing is hospital-level and DRG isn't used.
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	NY Medicaid Provider ID (MMIS, 8-digit). NY's state-issued billing identifier (universal across professionals and hospitals).
`opcert`1 required	string	Hospital-only NY operating certificate. Not all NY providers have one.
`provider_name`1 required	string	Hospital name (partial match, case-insensitive).
`service_type`	string	What category of inpatient care was delivered. Values: acute, psychiatric, specialty_acute, cah, med_rehab, chem_dep_rehab, dual_diag_adult, dual_diag_child. Optional; defaults to acute, or can be inferred from rate_code or APR-DRG.
`rate_code`	string	Optional 4-digit code from UB-04 Value Code 24. An alternate way to specify Service Type; e.g., 2946/2960 = acute, 2852 = psychiatric, 2853 = med_rehab, 2999 = cah, 4608 = dual_diag_adult, 4607 = dual_diag_child.
`payer_class`	string	Payer class. Values: FFS = traditional fee-for-service Medicaid claims. MMC = Managed Medicaid (insurer-administered) claims. MMC rates often include additional add-ons (Safety Net SDP + H+H ACR) auto-applied for qualifying hospitals on acute and psychiatric. Defaults to FFS.
`discharge_date`	string	Discharge date (MM/DD/YYYY or YYYY-MM-DD). Selects the rate period. Defaults to today.
`length_of_stay`	integer	Length of stay in days. Required for psychiatric and per-diem service types; optional for acute (used only for transfer calculations).
`alc_days`	integer	Days within the stay where the patient was medically stable enough to be discharged but couldn't be (e.g., awaiting nursing home placement). ALC days pay at the ALC per-diem rate. Not supported for Adult or Child Dual Diagnosis Psychiatric: NY doesn't publish an ALC per-diem for those service types, so supplying alc_days > 0 returns rate_found=false with an explanatory error.
`gross_charges`	decimal	Billed charges (acute only). Required to evaluate cost-outlier eligibility.
`transfer_out`	boolean	True if this hospital transferred the patient to another facility. Acute only. Payment is rebuilt as a daily rate (the DRG payment divided by the DRG's average length of stay, times a 120% adjustment factor, plus the hospital's capital per diem) applied to each non-ALC day, then capped at what a full discharge would have paid. The 120% factor does not apply when the DRG's average length of stay is 1, and transfer-only DRGs (580/581) are paid the full DRG rate. Per 10 NYCRR §86-1.21.
`age_group`	string	Psychiatric only. Values: ADULT, CHILD. CHILD applies when the patient is age 17 or under (adds 1.3597 multiplier to operating rate). Defaults to ADULT.
`has_intellectual_disability`	boolean	Psychiatric only. True if the patient has an Intellectual Disability diagnosis. Applies 1.0599 MR factor (max 1× per case).
`comorbidity_category`	string	Psychiatric only. Highest-matching comorbidity from NY's 18-category list (acute_coronary_syndrome, arrhythmia, cancers, cardio_respiratory_failure, cellulitis, chronic_kidney_disease, chronic_obstructive_lung_disease, diabetes, gi_hemorrhage, heart_failure, liver_disease, metabolic_disturbance, neurological_disease, opportunistic_infection, pancreas_disease, pneumonia, sepsis, severe_hematologic_disorder).
`ect_treatments`	integer	Psychiatric only. Number of electroconvulsive therapy treatments delivered during the stay.
`prior_admission_within_30d`	boolean	Psychiatric only. Set if the patient was discharged from a NY psychiatric unit within the prior 30 days.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Hospital NPI.
`state_provider_id`	string	NY Medicaid Provider ID (MMIS).
`opcert`	string	NY Operating Certificate number.
`provider_name`	string	Hospital name.
`provider_type_label`	string	Human-readable provider type (always 'Hospital' for NY IP).
`primary_taxonomy_code`	string	NPPES primary taxonomy code (NUCC standard).
`primary_taxonomy_display_name`	string	NPPES primary taxonomy display name (NUCC-enriched).
`street_address`	string	Hospital street address.
`city`	string	Hospital city.
`county`	string	Hospital county.
`state`	string	Hospital state.
`zip_code`	string	Hospital ZIP.
`billing_code`	string	User-supplied billing_code echoed verbatim. On per-diem service types this is whatever code the caller passed (typically an APR-DRG); it's echoed but not used in pricing. Null when no billing_code was supplied (legal on per-diem; required on acute/psychiatric).
`billing_code_type`	string	'APR-DRG' when the echoed billing_code matches the APR-DRG shape (e.g. '140-2'). Null when no billing_code was supplied.
`billing_code_description`	string	Service-type description (per-diem paths only; null on acute/psychiatric DRG lookups).
`billing_code_used_in_calculation`	boolean	FALSE on per-diem service types where billing_code was echoed but not used in pricing. Suppressed (null) on acute/psychiatric where the billing_code (APR-DRG) is the primary pricing input.
`rate_code`	string	NY rate code echoed from request.
`service_type`	string	Resolved service type used for calculation.
`service_type_source`	string	How service_type was determined. Values: explicit, inferred_from_rate_code, inferred_from_drg, sole_provider_certification, default_acute.
`apr_drg_code`	string	APR-DRG code (acute/psychiatric only).
`soi`	integer	Severity of Illness 1-4.
`payer_class`	string	Payer class echoed. Values: FFS, MMC.
`payer_class_label`	string	Human-readable payer class: 'Fee-for-Service' or 'Managed Medicaid'.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`siw`	decimal	Acute APR-DRG Service Intensity Weight.
`psych_siw`	decimal	Psychiatric APR-DRG SIW (separate from acute SIW).
`alos`	decimal	Average Length of Stay. Surfaced only on transfer cases (used in the transfer per-diem calc).
`statewide_base_price_used`	decimal	Statewide base price for the payer class (acute); background context, not a formula input.
`isaf_used`	decimal	Input Service Adjustment Factor (acute). Surfaced only when a cost outlier is being evaluated.
`discharge_rate_used`	decimal	Discharge Case Payment Rate for the matched hospital × payer class × period.
`dme_used`	decimal	Direct Medical Education amount paid on FFS acute. Suppressed (null) on MMC acute since DME is bundled into IME and not paid separately.
`capital_per_disch_used`	decimal	Capital per discharge base rate for the payer class (acute): the published base column alone. On MMC the non-comparable add-ons are paid on top and reported separately, so each amount maps to its own published column. Null on transfer claims, which pay capital per diem instead.
`capital_addon_ambulance_mmc`	decimal	Non-comparable capital add-on: Ambulance (MMC acute). Null when zero or on transfer claims.
`capital_addon_teaching_election_mmc`	decimal	Non-comparable capital add-on: Teaching Election Amendment Physician (MMC acute). Null when zero or on transfer claims.
`capital_addon_school_nursing_mmc`	decimal	Non-comparable capital add-on: School of Nursing (MMC acute). Null when zero or on transfer claims.
`capital_addon_min_wage_mmc`	decimal	Non-comparable capital add-on: Minimum Wage (MMC acute). The most widely applied of the four. Null when zero or on transfer claims.
`capital_per_diem_used`	decimal	Capital per diem (acute). Surfaced only on transfer claims, where it replaces capital per discharge inside the daily rate.
`high_cost_cc_used`	decimal	Cost-to-charge ratio. Surfaced only when a cost outlier is being evaluated.
`base_dr_payment`	decimal	Computed: discharge_rate × siw (acute pre-add-ons).
`is_outlier_case`	boolean	TRUE when the cost-outlier rule fired. Suppressed (null) when not applicable; only surfaced as a positive callout.
`cost_of_case`	decimal	gross_charges × high_cost_cc (acute outlier).
`cost_outlier_threshold`	decimal	Per-DRG outlier threshold. Surfaced only when an outlier is being evaluated.
`outlier_threshold_adjusted`	decimal	cost_outlier_threshold × isaf.
`outlier_eligible_cost`	decimal	max(0, cost_of_case − threshold).
`outlier_marginal_pct`	decimal	0.60: NY's marginal cost percentage. Surfaced only when an outlier fired.
`outlier_amount`	decimal	Outlier dollar amount.
`is_transfer_case`	boolean	TRUE when the transfer methodology applied. Suppressed (null) when not applicable; only surfaced as a positive callout. Also null for transfer-only DRGs 580/581, which are paid the full DRG rate per 10 NYCRR §86-1.21(b)(2).
`transfer_days_used`	integer	Days priced at the transfer per diem: length_of_stay − alc_days. ALC days are paid separately at the ALC per diem.
`transfer_adjustment_factor`	decimal	1.20, or 1.00 when the DRG's average length of stay is 1 (10 NYCRR §86-1.21(b); the factor is not applied in that case).
`transfer_per_diem`	decimal	(base_dr_payment / alos × transfer_adjustment_factor) + capital_per_diem. Capital per diem is added after the factor, not multiplied by it.
`transfer_adjusted_amount`	decimal	min(transfer_per_diem × transfer_days_used, base_dr_payment + capital_per_disch). The cap is the full inlier payment, not the bare DRG base.
`acute_alc_per_diem_used`	decimal	Acute ALC per diem. Surfaced only when alc_days > 0.
`safety_net_sdp_per_disch_mmc`	decimal	Safety Net per-discharge add-on (MMC acute).
`hh_acr_per_disch_mmc`	decimal	H+H Average Commercial Rate per-discharge add-on (MMC acute, NYC public hospitals).
`psych_base_per_diem_used`	decimal	Psych base per-diem for payer class and age group.
`age_factor_used`	decimal	Psych age factor (1.3597 for CHILD ≤17). Suppressed (null) for ADULT; only surfaced when the multiplier shifted the per-diem.
`age_factor_reason`	string	Human-readable reason the age factor applied. Suppressed when no factor applied.
`mr_factor_used`	decimal	MR factor (1.0599 when intellectual disability declared). Suppressed (null) when no MR factor applied.
`mr_factor_reason`	string	Human-readable reason the MR factor applied. Suppressed when no factor applied.
`comorbidity_factor_used`	decimal	Highest-matching psych comorbidity factor. Suppressed (null) when no comorbidity selected.
`comorbidity_category_used`	string	Comorbidity category label. Suppressed when no comorbidity selected.
`psych_non_op_per_diem_used`	decimal	Psych non-operating per-diem amount.
`psych_ect_per_treatment_used`	decimal	Psych ECT per-treatment rate. Surfaced only when ect_treatments > 0.
`ect_treatments_used`	integer	ECT treatments echoed. Surfaced only when > 0.
`psych_alc_per_diem_used`	decimal	Psych ALC per-diem rate. Surfaced only when alc_days > 0.
`psych_sdp_per_diem_mmc`	decimal	Psych Safety Net SDP per-diem add-on (MMC). Surfaced only on MMC psychiatric when populated.
`psych_hh_acr_per_diem_mmc`	decimal	Psych H+H ACR per-diem add-on (MMC, NYC public hospitals). Surfaced only on MMC psychiatric when populated.
`psych_dme_mmc`	decimal	Psych DME amount paid on MMC. Surfaced only on MMC psychiatric when populated.
`los_scale_days_at_1_20`	integer	Days paid at the 1.20 scale factor (Days 1-4).
`los_scale_days_at_1_00`	integer	Days paid at 1.00 scale (Day 5 onward).
`los_scaled_total`	decimal	Effective scaled day count.
`prior_admission_within_30d_applied`	boolean	TRUE when readmission rule shifted Day 1 to Day-4 scaling. Suppressed (null) when not applicable.
`prior_admission_within_30d_used`	boolean	Echoed input. Suppressed (null) when FALSE.
`has_intellectual_disability_used`	boolean	Echoed input. Suppressed (null) when FALSE.
`age_group_used`	string	Echoed age group (ADULT / CHILD) for psychiatric.
`per_diem_used`	decimal	Per-diem rate (per-diem service types). Suppressed (null) when 0.
`alc_per_diem_used`	decimal	ALC per-diem (per-diem service types). Suppressed (null) when alc_days = 0 or per-diem = 0.
`specialty_acute_nyc_upl_mmc`	decimal	NYC UPL Conversion add-on (specialty_acute MMC, NYC public). Surfaced only when populated.
`length_of_stay_used`	integer	LOS used in computation. Echoed when supplied; surfaced unconditionally on psychiatric / per-diem (required input).
`non_alc_days`	integer	LOS − alc_days (per-diem).
`alc_days_used`	integer	ALC days echoed. Suppressed (null) when 0.
`gross_charges_used`	decimal	Charges echoed. Surfaced only when supplied.
`transfer_out_used`	boolean	transfer_out echoed. Suppressed (null) when FALSE; only surfaced as a positive callout.
`hcra_surcharge_pct_used`	decimal	HCRA surcharge percentage (constant 7.04% since 4/1/2009).
`hcra_surcharge_amount`	decimal	HCRA dollar amount included in payment_rate.
`discharge_date_used`	date	The discharge date the rate was priced against, echoed from the request. When you omit discharge_date, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/ny/inpatient/rate?\
  billing_code=140-2&\
  npi=1659307817&\
  payer_class=FFS&\
  discharge_date=2024-01-15" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1659307817",
    "state_provider_id": "01234567",
    "opcert": "0101000H",
    "provider_name": "ALBANY MEDICAL CENTER HOSPITAL",
    "city": "ALBANY",
    "county": "ALBANY",
    "state": "NY",
    "zip_code": "12208",
    "billing_code": "140-2",
    "billing_code_type": "APR-DRG",
    "billing_code_description": null,
    "service_type": "acute",
    "service_type_source": "explicit",
    "apr_drg_code": "140",
    "soi": 2,
    "payer_class": "FFS",
    "payer_class_label": "Fee-for-Service",
    "payment_rate": "7639.41",
    "payment_rate_type": "claim",
    "calculation_method": "$7,286.37 (Discharge Case Payment Rate) × 0.722 (SIW) = $5,260.76 (Base DRG Payment)\n+ $1,135.51 (Direct Medical Education) + $740.70 (Capital Per Discharge) + $502.44 (HCRA Surcharge 7.04%)\n= $7,639.41 (Total Payment)",
    "siw": "0.722",
    "discharge_rate_used": "7286.37",
    "dme_used": "1135.51",
    "capital_per_disch_used": "740.70",
    "base_dr_payment": "5260.76",
    "hcra_surcharge_pct_used": "0.0704",
    "hcra_surcharge_amount": "502.44",
    "statewide_base_price_used": "7460.06",
    "discharge_date_used": "2024-01-15",
    "effective_start_date": "2024-01-01",
    "effective_end_date": "2024-03-31"
  }
]

POST/ny/inpatient/rate/batch

Look up multiple NY inpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "140-2",
      "npi": "1659307817",
      "payer_class": "FFS"
    },
    {
      "billing_code": "750-1",
      "npi": "1417027558",
      "payer_class": "MMC",
      "service_type": "psychiatric",
      "length_of_stay": 10,
      "age_group": "CHILD"
    }
  ]
}

GET/ny/providers/search

New York Provider Search

Search for NY Medicaid providers by NPI, MMIS ID, OPCERT (Article 28 hospitals), name, location, or taxonomy. Returns provider details with rate availability.

Parameters

Name	Type	Description
`npi`	string	Provider NPI (10 digits).
`state_provider_id`	string	NY Medicaid Provider ID (MMIS, 8-digit).
`opcert`	string	NY Operating Certificate (Article 28 hospitals).
`provider_name`	string	Provider name (partial match, case-insensitive).
`city`	string	City (partial match).
`county`	string	County (partial match).
`zip_code`	string	ZIP code (exact match).
`ny_profession_or_service`	string	NY-published profession/service category (partial match). Examples: Physician, Nurse Practitioner, Podiatrist.
`ny_provider_specialty`	string	NY-published specialty sub-classification (partial match). Examples: Cardiology, Geriatric Medicine.
`taxonomy`	string	NPPES primary taxonomy display name (partial match). NUCC-enriched display name.
`provider_type`	string	Values: HOSPITAL, PHYSICIAN, OUTPATIENT_CLINIC_ASC, LABORATORY.
`limit`	integer	Max results (default 100, max 1000).

Returns

Field	Type	Description
`providers`	array	List of matching providers.
↳`npi`	string	Provider NPI.
↳`state_provider_id`	string	MMIS ID.
↳`opcert`	string	Operating Certificate (hospitals only).
↳`provider_name`	string	Provider name.
↳`provider_type`	string	NY provider type.
↳`provider_type_label`	string	Human-readable provider type.
↳`entity_type`	string	Individual or Organization.
↳`ny_profession_or_service`	string	NY profession/service category (comma-delimited title case).
↳`ny_provider_specialty`	string	NY specialty (comma-delimited title case).
↳`primary_taxonomy`	string	NPPES primary taxonomy display name (NUCC-enriched).
↳`street_address`	string	Street address.
↳`city`	string	City.
↳`county`	string	County.
↳`state`	string	State.
↳`zip_code`	string	ZIP.
↳`op_rates`	boolean	Has outpatient rates.
↳`ip_rates`	boolean	Has inpatient rates.
↳`available_service_types`	string[]	IP service_types this hospital publishes rates for (acute, psychiatric, specialty_acute, cah, med_rehab, chem_dep_rehab, dual_diag_adult, dual_diag_child). Values match the service_type input on /ny/inpatient/rate. Empty for non-hospitals.
`total_results`	integer	Total results found.
`limit_applied`	integer	Limit applied.

Request

curl "https://staterates.health/api/v1/ny/providers/search?\
  provider_type=HOSPITAL&\
  city=New+York" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

{
  "providers": [
    {
      "npi": "1417027558",
      "state_provider_id": "01234567",
      "opcert": "7000045H",
      "provider_name": "Bronxcare Hospital Center",
      "provider_type": "HOSPITAL",
      "provider_type_label": "Hospital",
      "entity_type": "Organization",
      "ny_profession_or_service": "Hospital - Inpatient, Outpatient",
      "ny_provider_specialty": null,
      "primary_taxonomy": "General Acute Care Hospital",
      "street_address": "1650 Selwyn Avenue",
      "city": "Bronx",
      "county": "Bronx",
      "state": "NY",
      "zip_code": "10457",
      "op_rates": true,
      "ip_rates": true,
      "available_service_types": [
        "acute",
        "psychiatric"
      ]
    }
  ],
  "total_results": 1,
  "limit_applied": 100
}

GET/oh/outpatient/rate

Ohio Outpatient Rates

Look up an Ohio Medicaid outpatient rate. Physicians, imaging centers, and clinical labs are reimbursed by HCPCS code from fee schedules (MSRIAP for physicians and imaging, the Clinical Lab schedule for labs). Hospitals and ASCs are reimbursed per claim using EAPG rates.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	HCPCS code (e.g., 99213) or EAPG code (e.g., 00002).
`billing_code_type`	string	Code system filter. Values: HCPCS, EAPG. If omitted, returns results for all matching code systems.
`npi`1 required	string	National Provider Identifier (10 digits).
`provider_name`1 required	string	Provider name (partial match, case-insensitive). Returns rates for all matches.
`provider_type`	string	State Rates provider classification. Values: HOSPITAL, PHYSICIAN, ASC, CLINICAL_LABORATORY, IMAGING_CENTER. If omitted, returns rates across all matching provider types for the code.
`modifier`	string	Modifier. Values: 26 (Professional Component), TC (Technical Component). Matched to a pre-multiplied row in the data layer; modifier_adjustment in the response carries the multiplier when one was applied. Other modifiers (e.g., 'QW' for CLIA-waived lab) match published per-modifier rows directly when present.
`place_of_service`	string	Place of service (MSRIAP only; ignored for EAPG). Values: facility, non_facility. If omitted, returns the source default rate (typically non-facility).
`date_of_service`	string	Date of service (MM/DD/YYYY or YYYY-MM-DD). Defaults to today. Selects the fee schedule (HCPCS) or relative-weight version (EAPG) in effect on this date.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`provider_name`	string	Provider name.
`provider_type`	string	State Rates provider classification.
`provider_type_label`	string	Human-readable provider type label.
`hospital_class`	string	Derived facility-type classification (HOSPITAL only). Values: Critical Access, Children's, Teaching, Rural, Psychiatric, General Acute Care. Psychiatric is assigned when the hospital has a published psych per-diem rate (FSP); other hospitals fall back to peer-group bucketing.
`primary_taxonomy_code`	string	NPPES primary taxonomy code (non-hospital providers).
`primary_taxonomy_display_name`	string	NPPES primary taxonomy display name.
`street_address`	string	Provider street address.
`city`	string	Provider city.
`county`	string	Provider county.
`state`	string	Provider state (always 'OH').
`zip_code`	string	Provider ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system. Values: HCPCS, APR-DRG.
`billing_code_description`	string	Human-readable code description. Populated for HCPCS Level II codes (CMS-sourced); null for CPT (HCPCS Level I) and EAPG/APG codes, whose descriptions are licensed content.
`modifier`	string	Modifier applied (e.g., '26', 'TC', 'QW').
`modifier_adjustment`	decimal	Multiplier applied to base_rate to derive payment_rate. Populated only when the rate is a derived modifier row (currently MSRIAP modifier 26 / TC). NULL when payment_rate is published as-is: base rates, Lab modifier rows where ODM publishes the modified rate flat (QW / 26 / TC), and EAPG. HCPCS path only.
`place_of_service`	string	Place of service used (MSRIAP only).
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`eapg_weight`	decimal	EAPG relative weight (Solventum 3M v3.17). EAPG path only.
`asc_flat_base`	decimal	ASC statewide flat base rate ($90.98 for 1/1/2024+, $83.34 for 1/2/2020–12/31/2023). ASC path only.
`outpatient_base_rate`	decimal	Hospital-specific OP base rate. Hospital EAPG path only.
`op_cca_rate`	decimal	Hospital OP Cost-Coverage Add-on per detail line. Hospital EAPG path only.
`xix_op_ccr`	decimal	Hospital XIX OP cost-to-charge ratio (reference value). Hospital EAPG path only.
`base_rate`	decimal	Source fee-schedule rate for this code/POS before any modifier adjustment. When modifier_adjustment is populated, payment_rate = base_rate × modifier_adjustment (cent-rounded). When no adjustment was applied, base_rate equals payment_rate. HCPCS path only.
`hospital_pa_advisory`	string	MSRIAP prior-auth advisory text. HCPCS path only.
`is_manually_priced`	boolean	MSRIAP sentinel: rate is determined case-by-case (BR/FP/PA/PC). payment_rate=$0.00 with explanatory message.
`is_flat_rate`	boolean	EAPG sentinel: flat-rate EAPG paid by OAC policy not weight × base (FR sentinel). payment_rate=NULL with explanatory message.
`date_of_service_used`	date	The date of service the rate was priced against, echoed from the request. When you omit date_of_service, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/oh/outpatient/rate?\
  billing_code=99213&\
  npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "provider_name": "OHIO MEDICAL GROUP",
    "provider_type": "PHYSICIAN",
    "provider_type_label": "Physician",
    "hospital_class": null,
    "primary_taxonomy_code": "207R00000X",
    "primary_taxonomy_display_name": "Internal Medicine",
    "street_address": "100 MAIN ST",
    "city": "COLUMBUS",
    "county": "FRANKLIN",
    "state": "OH",
    "zip_code": "43215",
    "billing_code": "99213",
    "billing_code_type": "HCPCS",
    "billing_code_description": null,
    "modifier": null,
    "modifier_adjustment": null,
    "place_of_service": "non_facility",
    "payment_rate": "46.23",
    "payment_rate_type": "fee_schedule",
    "calculation_method": "MSRIAP Fee Schedule (Non-Facility) = $46.23",
    "eapg_weight": null,
    "asc_flat_base": null,
    "outpatient_base_rate": null,
    "op_cca_rate": null,
    "xix_op_ccr": null,
    "base_rate": "46.23",
    "hospital_pa_advisory": "No PA",
    "is_manually_priced": false,
    "is_flat_rate": null,
    "date_of_service_used": "2026-08-01",
    "effective_start_date": "2026-01-01",
    "effective_end_date": null
  }
]

POST/oh/outpatient/rate/batch

Look up multiple OH outpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "99213",
      "npi": "1234567890"
    },
    {
      "billing_code": "00002",
      "billing_code_type": "EAPG",
      "npi": "1043641897"
    }
  ]
}

GET/oh/inpatient/rate

Ohio Inpatient Claims

Look up an Ohio Medicaid APR-DRG inpatient payment rate. Incorporates capital and medical-education add-ons, cost outliers, transfer per-diem caps, and special claim types such as Medicare crossovers, organ acquisition, and psychiatric per-diems.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	APR-DRG code. Accepts '140-2', '140', '0140-2', '0140', or '1402' (composite is parsed into apr_drg_code + soi).
`npi`1 required	string	National Provider Identifier (10 digits).
`provider_name`1 required	string	Hospital name (partial match, case-insensitive).
`discharge_date`	string	Discharge date (MM/DD/YYYY or YYYY-MM-DD). Defaults to today. Drives all DRG pricing parameter lookups.
`transfer_claim`	boolean	Transfer claim. Discharge status 02, 05, 63, 65, 66, 82, 85, 91, 93, or 94 (transferred to another facility).
`interim_claim`	boolean	Interim claim: a long stay billed in periodic interim increments, reconciled to the final DRG at discharge.
`length_of_stay`	integer	LOS in days. Required for transfer + interim. Defaults to the DRG's average length of stay.
`total_charges`	decimal	Covered billed charges. Required for the outlier, interim, lesser-of-charges, and organ-acquisition paths.
`crossover_claim`	boolean	Medicare-Medicaid dual-eligible crossover claim? Swaps base rate + IP CCR to medicare_crossover_* columns. Capital, Med-ED, IP CCA stay on standard columns.
`organ_acquisition`	boolean	Organ acquisition claim (heart, lung, liver, or pancreas). Requires total_charges.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Hospital NPI.
`provider_name`	string	Hospital name.
`hospital_class`	string	Derived facility-type classification. Values: Critical Access, Children's, Teaching, Rural, Psychiatric, General Acute Care. Psychiatric is assigned when the hospital has a published psych per-diem rate (FSP); other hospitals fall back to peer-group bucketing.
`street_address`	string	Hospital street address.
`city`	string	Hospital city.
`county`	string	Hospital county.
`state`	string	Hospital state.
`zip_code`	string	Hospital ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system: APR-DRG.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`apr_drg_code`	string	Base APR-DRG code (3-digit).
`soi`	integer	Severity of Illness (1–4).
`casemix_relative_weight`	decimal	OH-published DRG relative weight for this (DRG, SOI).
`average_length_of_stay`	decimal	Statewide average length of stay for this DRG (drives transfer per-diem calc).
`is_not_covered`	boolean	DRG flagged 'Not Covered' in source (specific transplants under DRG 772).
`inpatient_base_rate`	decimal	Hospital IP base rate (or medicare_crossover_ip_base_rate when crossover_claim=true).
`capital_rate`	decimal	Hospital combined capital rate.
`meded_rate`	decimal	Hospital Med-ED rate (0 for non-eligible hospitals).
`ip_cca_rate`	decimal	Hospital IP CCA per-discharge rate.
`xix_ip_ccr`	decimal	Hospital XIX IP cost-to-charge ratio (used for outlier and interim calculations).
`psych_per_diem_rate`	decimal	FSP psych per-diem rate. FSP path only.
`drg_base_payment`	decimal	DRG Base Payment = inpatient_base_rate × casemix_relative_weight.
`capital_allowance`	decimal	Capital Allowance = capital_rate × casemix_relative_weight.
`meded_allowance`	decimal	Med-ED Allowance = meded_rate × casemix_relative_weight.
`cca_amount`	decimal	IP CCA flat amount per discharge.
`outlier_adjustment_applied`	boolean	Whether the cost-outlier add-on fired.
`outlier_threshold`	decimal	Outlier threshold = drg_base_payment + fixed_outlier_threshold.
`fixed_outlier_threshold`	decimal	Fixed threshold per SPA §F: $50,000 for neonate/tracheostomy, $75,000 otherwise.
`outlier_threshold_basis`	string	Basis used: 'neonate', 'tracheostomy', or 'standard'.
`estimated_cost`	decimal	cost_of_case = total_charges × xix_ip_ccr.
`outlier_eligible_cost`	decimal	eligible_outlier_cost = estimated_cost − outlier_threshold (when positive).
`outlier_marginal_pct`	decimal	Outlier marginal cost percentage applied (80% per SPA §F).
`outlier_amount`	decimal	Outlier add-on = eligible_outlier_cost × outlier_marginal_pct.
`transfer_adjustment_applied`	boolean	Whether the transfer per-diem cap reduced the DRG base payment.
`statewide_avg_los`	decimal	Statewide average LOS used for transfer per-diem (= DRG average_length_of_stay).
`transfer_per_diem`	decimal	Transfer per-diem = (inpatient_base_rate × casemix_relative_weight) / statewide_avg_los.
`transfer_per_diem_total`	decimal	transfer_per_diem × (length_of_stay + 1).
`transfer_adjusted_amount`	decimal	DRG base after transfer cap = min(transfer_per_diem_total, drg_base_payment).
`interim_payment_applied`	boolean	Whether the interim-claim cost-based pricing path was used.
`interim_payment_amount`	decimal	Interim payment = xix_ip_ccr × total_charges.
`fsp_per_diem_applied`	boolean	Whether the FSP psych per-diem path was used (hospital has psych_per_diem_rate > 0).
`fsp_per_diem_amount`	decimal	FSP per-diem payment = length_of_stay × psych_per_diem_rate.
`organ_acquisition_applied`	boolean	Whether the organ-acquisition 100%-of-charges rule was used.
`organ_acquisition_amount`	decimal	Organ acquisition payment = total_charges.
`crossover_claim_applied`	boolean	Whether the Medicare crossover formula path was used.
`charge_cap_applied`	boolean	Whether the lesser-of-charges cap reduced the final payment (only fires when outlier qualifies, per SPA §F(3)).
`length_of_stay_used`	integer	LOS used in calculation.
`total_charges_used`	decimal	Total charges used in calculation.
`discharge_date_used`	date	The discharge date the rate was priced against, echoed from the request. When you omit discharge_date, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/oh/inpatient/rate?\
  billing_code=140-2&\
  npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "provider_name": "OHIO GENERAL HOSPITAL",
    "hospital_class": "General Acute Care",
    "street_address": "500 HOSPITAL DR",
    "city": "CLEVELAND",
    "county": "CUYAHOGA",
    "state": "OH",
    "zip_code": "44106",
    "billing_code": "140-2",
    "billing_code_type": "APR-DRG",
    "payment_rate": "3794.04",
    "payment_rate_type": "claim",
    "calculation_method": "Standard DRG: ($4897.92 (Hospital IP Base Rate) + $404.37 (Capital Rate) + $235.70 (Med-ED Rate)) × 0.569068 (DRG/SOI Relative Weight) + $642.55 (IP CCA per Discharge) = $3794.04 (Standard Payment).",
    "apr_drg_code": "140",
    "soi": 2,
    "casemix_relative_weight": "0.569068",
    "average_length_of_stay": "4.20",
    "is_not_covered": false,
    "inpatient_base_rate": "5897.21",
    "capital_rate": "954.50",
    "meded_rate": "0.00",
    "ip_cca_rate": "-105.50",
    "xix_ip_ccr": "0.2800",
    "psych_per_diem_rate": null,
    "drg_base_payment": "3356.27",
    "capital_allowance": "543.27",
    "meded_allowance": "0.00",
    "cca_amount": "-105.50",
    "outlier_adjustment_applied": false,
    "outlier_threshold": null,
    "fixed_outlier_threshold": null,
    "outlier_threshold_basis": null,
    "estimated_cost": null,
    "outlier_eligible_cost": null,
    "outlier_marginal_pct": null,
    "outlier_amount": null,
    "transfer_adjustment_applied": false,
    "statewide_avg_los": null,
    "transfer_per_diem": null,
    "transfer_per_diem_total": null,
    "transfer_adjusted_amount": null,
    "interim_payment_applied": false,
    "interim_payment_amount": null,
    "fsp_per_diem_applied": false,
    "fsp_per_diem_amount": null,
    "organ_acquisition_applied": false,
    "organ_acquisition_amount": null,
    "crossover_claim_applied": false,
    "charge_cap_applied": false,
    "length_of_stay_used": 4,
    "total_charges_used": null,
    "discharge_date_used": "2026-08-01",
    "effective_start_date": "2025-07-01",
    "effective_end_date": null
  }
]

POST/oh/inpatient/rate/batch

Look up multiple OH inpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "140-2",
      "npi": "1234567890"
    },
    {
      "billing_code": "194-1",
      "npi": "9876543210",
      "length_of_stay": 7,
      "total_charges": "120000",
      "transfer_claim": true
    }
  ]
}

GET/oh/providers/search

Ohio Provider Search

Search for Ohio Medicaid providers by NPI, name, location, taxonomy, provider type, or hospital class. Returns provider details with rate availability.

Parameters

Name	Type	Description
`npi`	string	National Provider Identifier (10 digits).
`provider_name`	string	Provider name (partial match, case-insensitive).
`city`	string	City (partial match).
`county`	string	County (partial match).
`zip_code`	string	ZIP code (exact match).
`taxonomy`	string	NUCC taxonomy display name (partial match, non-hospital).
`provider_type`	string	State Rates provider classification. Values: HOSPITAL, PHYSICIAN, ASC, CLINICAL_LABORATORY, IMAGING_CENTER.
`hospital_class`	string	Hospital classification filter (HOSPITAL only). Values: Critical Access, Children's, Teaching, Rural, Psychiatric, General Acute Care.
`limit`	integer	Max results (default 100, max 1000).

Returns

Field	Type	Description
`providers`	array	List of matching providers.
↳`npi`	string	Provider NPI.
↳`provider_name`	string	Provider name.
↳`provider_type`	string	State Rates provider classification.
↳`provider_type_label`	string	Human-readable provider type label.
↳`entity_type`	string	Individual or Organization (always 'Organization' for HOSPITAL).
↳`primary_taxonomy`	string	NPPES primary taxonomy display name (non-hospital).
↳`hospital_class`	string	Derived facility-type classification (HOSPITAL only). Values: Critical Access, Children's, Teaching, Rural, Psychiatric, General Acute Care.
↳`street_address`	string	Street address.
↳`city`	string	City.
↳`county`	string	County.
↳`state`	string	State.
↳`zip_code`	string	ZIP code.
↳`op_rates`	boolean	Has outpatient rates.
↳`ip_rates`	boolean	Has inpatient rates.
`total_results`	integer	Total results found.
`limit_applied`	integer	Limit applied.

Request

curl "https://staterates.health/api/v1/oh/providers/search?\
  provider_name=cleveland&\
  provider_type=HOSPITAL" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

{
  "providers": [
    {
      "npi": "1234567890",
      "provider_name": "OHIO GENERAL HOSPITAL",
      "provider_type": "HOSPITAL",
      "provider_type_label": "Hospital",
      "entity_type": "Organization",
      "primary_taxonomy": null,
      "hospital_class": "General Acute Care",
      "street_address": "500 HOSPITAL DR",
      "city": "CLEVELAND",
      "county": "CUYAHOGA",
      "state": "OH",
      "zip_code": "44106",
      "op_rates": true,
      "ip_rates": true
    }
  ],
  "total_results": 1,
  "limit_applied": 100
}

GET/tx/outpatient/rate

Texas Outpatient Rates

Look up a Texas Medicaid outpatient rate by HCPCS code and provider. Professional claims use fee schedules posted by TMHP, while hospital outpatient services use a combination of these same fee schedules and percent-of-charge reimbursement. Rates with and without CHIRP managed-care increases are provided.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	HCPCS/CPT procedure code (e.g., 99213).
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	TPI: Texas Provider Identifier (hospitals only).
`ccn`1 required	string	CMS Certification Number (exact match, hospitals only).
`provider_name`1 required	string	Provider name (partial match, min 2 characters).
`provider_type`	string	State Rates provider classification. Values: PHYSICIAN, HOSPITAL, ASC_HASC, HOSPITAL_OP_IMAGING, CLINICAL_LABORATORY, OUTPATIENT_BEHAVIORAL_HEALTH, AMBULANCE. If omitted, resolved from taxonomy.
`child_patient`	boolean	True if patient is under 21 years of age. Defaults to false (adult).
`place_of_service`	string	Place of service (Physician only). Values: facility, non_facility. Defaults to non_facility.
`area_type`	string	Hospital classification (Hospital OP Imaging only). Values: urban, rural.
`lab_type`	string	Lab fee tier (Clinical Laboratory only). Values: clin_lab, sch, dshs. Defaults to clin_lab.
`modifier`	string	Procedure modifier. Values: 26 (Professional Component), TC (Technical Component), or any TX state-specific modifier published on the row (e.g., U1, U3, UB, TH). Exact-match; unmatched modifiers return rate_found=false.
`billed_charges`	decimal	Total billed charges. Required for hospital percent_of_charges codes.
`emergency_room`	boolean	True if ER procedure. For hospitals, ASC surgical codes fall back to percent_of_charges (per TAC §355.8061).
`date_of_service`	string	Date of service (MM/DD/YYYY or YYYY-MM-DD). Defaults to today.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	TPI: Texas Provider Identifier.
`provider_name`	string	Provider name.
`provider_type`	string	State Rates provider classification used. Values: PHYSICIAN, HOSPITAL, ASC_HASC, HOSPITAL_OP_IMAGING, CLINICAL_LABORATORY, OUTPATIENT_BEHAVIORAL_HEALTH, AMBULANCE.
`provider_type_label`	string	Human-readable label for the State Rates provider classification (e.g., Physician, Hospital).
`hospital_class`	string	Hospital classification. Values: Urban, Rural, Childrens, STATE OWNED TEACHING.
`high_volume_provider`	boolean	High volume Medicaid provider.
`ccn`	string	CMS Certification Number (hospitals only).
`street_address`	string	Provider street address.
`city`	string	Provider city.
`county`	string	Provider county.
`zip_code`	string	Provider ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system. Values: HCPCS, APR-DRG.
`billing_code_description`	string	Human-readable code description. Populated for HCPCS Level II codes (CMS-sourced); null for CPT (HCPCS Level I) and EAPG/APG codes, whose descriptions are licensed content.
`payment_rate`	decimal	Payment rate in dollars. 0.00 when payment_rate_type is not_payable.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, not_payable (TMHP's fee lookup explicitly lists the code as not payable for outpatient hospital claims at the date of service).
`ofl_determination`	string	TMHP Online Fee Lookup payability class for this code and date (hospital outpatient only). Values: contracted (explicitly payable at contracted rate), not_payable (explicitly not payable), no_determination (the lookup's batch files carry no listing, so the line prices at a percentage of charges per TMPPM Hospital Services Handbook §4.5.2; see the accompanying advisory). Null wherever OFL payability does not gate the row: codes priced from a posted fee schedule, and the emergency-surgery fallback (an on-schedule ASC code performed in an emergency room, which TAC §355.8061 reimburses at a percentage of charges).
`calculation_method`	string	Human-readable calculation formula with actual values. Percent-of-charges codes that TMHP's fee lookup explicitly confirms carry “Payable at contracted rate per TMHP's fee lookup.”
`procedure_type_used`	string	Procedure type used for rate selection.
`tos_code`	string	Type of Service code.
`tos_description`	string	Type of Service description (e.g., MEDICAL SERVICES, SURGERY).
`modifier`	string	Modifier on the matched rate row. Sourced from the row, not echoed from the request; when no row matches the requested modifier, rate_found=false.
`modifier_adjustment`	decimal	Derived ratio against the unmodified base rate, populated on PC (modifier=26) and TC (modifier=TC) rows where a base sibling exists in the same partition. Typical values: ~0.3 for PC, ~0.7 for TC; PC + TC sums to 1.0 when both come from the same partition. NULL on base rows, state-modifier rows, hospital rows, and the ~4% of PC/TC rows where no base sibling is published in the source.
`place_of_service`	string	Place of service used.
`area_type`	string	Urban/Rural (Hospital OP Imaging only).
`lab_type`	string	Lab tier (Clinical Laboratory only).
`age_group`	string	Age group used. Values: ADULT, CHILD, ALL.
`is_manually_priced`	boolean	True if rate requires manual review.
`emergency_room`	boolean	True if ER procedure was specified.
`medicaid_fee`	decimal	Pre-adjustment Medicaid fee (professional only).
`total_rvus`	decimal	RVUs (Physician only).
`conversion_factor`	decimal	Conversion factor (Physician only).
`outpatient_rcc`	decimal	Outpatient interim rate (RCC).
`pct_allowable_charges`	decimal	Percentage of allowable charges.
`effective_rate`	decimal	Pre-calculated effective rate: RCC × pct allowable.
`source_fee_schedule`	string	Source fee schedule: ASC_HASC, HOSPITAL_OP_IMAGING.
`billed_charges`	decimal	Billed charges provided.
`calculation_note`	string	Note when charges not provided or manual pricing.
`chirp_adjustments`	object	CHIRP adjustment per managed care program (STAR, STAR_PLUS, STAR_KIDS). Hospital only. Each contains outpatient_rate_increase, chirp_multiplier, and adjusted_payment.
`advisories`	array	Informational advisories (hospital claims only), each with code and message. Present only when applicable; e.g., NO_CODE_LEVEL_DETERMINATION when TMHP's fee lookup batch files do not list the code and it is priced at a percentage of charges per TMPPM Hospital Services Handbook §4.5.2.
`date_of_service_used`	date	The date of service the rate was priced against, echoed from the request. When you omit date_of_service, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/tx/outpatient/rate?\
  billing_code=99213&\
  npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "state_provider_id": null,
    "provider_name": "SMITH FAMILY MEDICINE",
    "provider_type": "PHYSICIAN",
    "provider_type_label": "Physician",
    "hospital_class": null,
    "high_volume_provider": null,
    "ccn": null,
    "street_address": "200 MAIN ST",
    "city": "HOUSTON",
    "county": "HARRIS",
    "zip_code": "77001",
    "billing_code": "99213",
    "billing_code_type": "HCPCS",
    "billing_code_description": null,
    "payment_rate": "62.84",
    "payment_rate_type": "fee_schedule",
    "calculation_method": "Medicaid Fee (non-facility)",
    "procedure_type_used": null,
    "tos_code": "1",
    "tos_description": "MEDICAL SERVICES",
    "modifier": null,
    "modifier_adjustment": null,
    "place_of_service": "non_facility",
    "area_type": null,
    "lab_type": null,
    "age_group": "ADULT",
    "is_manually_priced": false,
    "emergency_room": null,
    "medicaid_fee": "62.84",
    "total_rvus": "2.40",
    "conversion_factor": "26.18",
    "outpatient_rcc": null,
    "pct_allowable_charges": null,
    "effective_rate": null,
    "source_fee_schedule": null,
    "billed_charges": null,
    "calculation_note": null,
    "chirp_adjustments": null,
    "date_of_service_used": "2026-08-01",
    "effective_start_date": "2024-09-01",
    "effective_end_date": null
  }
]

POST/tx/outpatient/rate/batch

Look up multiple TX outpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "npi": "1234567890",
      "billing_code": "99213"
    },
    {
      "npi": "1234567890",
      "billing_code": "99214",
      "child_patient": true
    }
  ]
}

POST/tx/outpatient/claim

Texas Outpatient Claims

Price a whole Texas Medicaid institutional outpatient claim (UB-04, type of bill 131) in one request: claim header plus up to 99 lines, with optional per-line service dates for claims spanning multiple days. Identify the billing hospital by NPI or CCN. Applies Texas claims-level outpatient reimbursement rules per the Texas Medicaid Provider Procedures Manual (TMPPM), 1 Tex. Admin. Code §355.8061, and Texas HHS billing guidance, and screens every claim against the CMS Medicaid NCCI procedure-to-procedure and MUE unit-limit edit files. Returns per-line allowed amounts, the fee-for-service claim total, CHIRP managed care adjusted totals, and informational flags. Returns expected reimbursement for a clean, payable claim.

Parameters

Name	Type	Description
`npi`1 required	string	Billing hospital NPI (10 digits). Provide npi or ccn.
`ccn`1 required	string	CMS Certification Number (6 characters, e.g. 450035). Provide npi or ccn.
`date_of_service`required	string	Statement date of service (MM/DD/YYYY or YYYY-MM-DD). Drives the rate and provider period used.
`emergency`	boolean	True for emergency/unscheduled claims. Emergency surgery prices itemized (cost-reimbursed) instead of the day-surgery global fee; false applies the non-emergent ER differential to ER visit lines. Defaults to false.
`child_patient`	boolean	True if patient is under 21 years of age. Defaults to false (adult).
`type_of_bill`	string	UB-04 type of bill. Only 131 (hospital outpatient) is supported; omit or pass 131. Nonpatient lab (141) and Medicare crossover claims are rejected.
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`lines`required	array	Claim lines (1–99). Each line: revenue_code (required; 3 or 4 digits), hcpcs (required for revenue codes Texas marks procedure-code-required: lab, imaging, ER, therapy), modifier, units (defaults to 1), billed_charges (required for cost-reimbursed lines; enables the lesser-of rule on fee schedule lines), and service_date (optional; defaults to the header date_of_service). On claims spanning multiple days, set service_date per line so the same-day checks (NCCI code pairs, daily unit limits, panel consolidation, ER bundling) group lines by the day the service actually occurred. Rates and the provider period always follow the header date_of_service.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`claim_priced`	boolean	False when the claim could not be priced at all (hospital not found, no cost-report data).
`error_message`	string	Explanation when claim_priced is false.
`npi`	string	Billing hospital NPI (echoed).
`child_patient_used`	boolean	Echo of child_patient. True when submitted as true; null otherwise.
`provider_name`	string	Hospital name.
`ccn`	string	CMS Certification Number.
`hospital_class`	string	Hospital classification. Values: Urban, Rural, Childrens, STATE OWNED TEACHING.
`area_type`	string	urban or rural (derived from hospital_class).
`high_volume_provider`	boolean	High volume Medicaid provider.
`pricing_path`	string	How the claim priced. Values: day_surgery (global payment: the highest-rated surgical procedure pays, other lines bundle to $0), itemized (each line priced independently and summed).
`claim_total`	decimal	Fee-for-service expected reimbursement for the claim (sum of line allowed amounts).
`total_billed_charges`	decimal	Sum of line billed charges, when provided.
`total_lines`	integer	Number of lines submitted.
`lines_priced`	integer	Number of lines with an allowed amount (including $0 bundled lines).
`lines`	array	Per-line results, in submitted order. Each line: rate_found, pricing_bucket (asc_hasc_fee_schedule, clinical_lab_fee_schedule, imaging_fee_schedule, percent_of_charges, bundled, manually_priced, not_a_benefit, not_separately_payable, not_payable_to_facility, not_payable, or fee_schedule as a rare fallback), bundled, allowed_amount, hcpcs_description, calculation_method, ofl_determination, advisories, and echoes of the inputs including the line's service_date. ofl_determination carries the same payability class as the single-code endpoint (contracted, not_payable, no_determination, or null), and is unaffected by bundling rules, which change what a line pays rather than the code's payability. advisories carries the same {code, message} shape as the single-code endpoint, and is null on lines a claim-level rule repriced (bundling, ER/observation absorption, the non-emergent ER cap), where the flag and calculation_method explain the amount instead.
`claim_calculation`	string	How the claim total was assembled: pricing path, bundling, reductions, and total, with actual values.
`rules_applied`	array	Machine-readable claim-rule events in the order applied (e.g., day_surgery_global, obs_absorbs_er, non_emergent_er_cap, lesser_of). claim_calculation is rendered from exactly these events.
`chirp_adjustments`	object	CHIRP managed care adjusted claim totals per program (STAR, STAR_PLUS, STAR_KIDS), each with the rate increase, multiplier, adjusted total, and the arithmetic. Models the fee-for-service floor. Individual MCO contract terms can pay differently.
`flags`	array	Informational flags, each {code, line, message}: a machine-readable code, the claim line it refers to (null when claim-level), and a plain-English explanation with the Texas Medicaid manual citation. Flags never change the returned pricing. Every code is listed in the flag legend below.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Flag legend

Flags are informational. They never change the returned pricing. Applied-rule flags accompany amounts the pricing already reflects; denial-risk flags mark amounts an adjudicator may pay differently; line-handling flags explain lines that could not be priced as submitted.

Applied payment rules (amounts already reflect these)

`ER_ABSORBED_BY_OBSERVATION`	Observation of 8+ hours absorbs the ER visit; ER lines pay $0.
`BRIEF_OBSERVATION_NOT_REIMBURSED`	Observation under 8 hours folds into the ER visit; observation lines pay $0.
`ER_INJECTION_ADMIN_BUNDLED`	Injection/infusion administration is included in the ER charge; pays $0.
`CRITICAL_CARE_NOT_PAYABLE_TO_FACILITY`	Critical care visit codes pay the treating physician, not the hospital.
`NON_EMERGENT_ER_REDUCTION`	Non-emergent ER visit reduced: flat fee, or 55% of allowed at rural hospitals.
`HIGH_VOLUME_UPLIFT_APPLIED`	Designated high-volume provider; day-surgery payment increased 5.2%.
`DEVICE_BUNDLED`	Device bundled into the day-surgery global payment.
`DEVICE_PAID_SEPARATELY`	Device with its own published fee; paid separately from the day-surgery global.
`NOT_A_BENEFIT`	Revenue code is not a Texas Medicaid benefit; pays $0.
`INCOMPLETE_SURGERY_MODIFIER`	Modifier 73/74: the state suspends these claims for manual review; priced at the full rate.

Denial-risk notices (line still priced in full)

`NCCI_PTP_CONFLICT`	Billed with its NCCI column-1 partner code on the same day; the component line denies on adjudication.
`MUE_UNITS_EXCEEDED`	Units exceed the Medicaid daily maximum for this code.
`MULTICHANNEL_LAB_PANEL_SUSPECTED`	Same-day automated lab panels are consolidated to a combined fee.
`PACKAGED_SERVICE_EXCLUSION_RISK`	Priced under cost reimbursement, but payers commonly package or exclude this service.
`OBSERVATION_OVER_48H`	Observation beyond 48 total hours is denied.
`OBS_761_CONFLICT`	Revenue code 761 denies when billed the same day as 760, 762, or 769.
`EMTALA_451_STANDALONE`	EMTALA screening pays as a stand-alone service; other lines are not separately reimbursed.
`OBS_CONCURRENT_ACTIVE_MONITORING`	Observation may overlap a procedure whose active monitoring is already included.
`RECOVERY_OBS_OVERLAP`	Recovery room hours and observation hours cannot be billed for the same time.
`IIP_E0782_E0783_MUTEX`	Only one implantable infusion pump code is payable per day.
`TMHP_CODE_PAIR_EDIT`	A Texas code-pair rule denies or bundles this line with another code on the claim.
`RURAL_ER_SCOPE_UNCERTAIN`	The rural ER reduction was applied to the visit line only; its exact scope is unconfirmed.

Line handling

`INVALID_REVENUE_CODE`	Not a valid Texas outpatient hospital revenue code; line skipped, claim still prices.
`MISSING_REQUIRED_HCPCS`	This revenue code requires a procedure code on the line; line skipped, claim still prices.
`MANUALLY_PRICED_LINE`	No published fee: the state prices this code manually; excluded from the claim total.
`PROFESSIONAL_MODIFIER_IGNORED`	Modifier 26/TC ignored; facilities do not bill professional/technical splits.

Request

curl -X POST "https://staterates.health/api/v1/tx/outpatient/claim" \
  -H "Authorization: Bearer YOUR_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{
    "npi": "1234567890",
    "date_of_service": "2026-04-16",
    "emergency": false,
    "lines": [
      {"revenue_code": "0360", "hcpcs": "33208", "units": 1, "billed_charges": 45200.00},
      {"revenue_code": "0278", "hcpcs": "C1785", "units": 1, "billed_charges": 22900.00},
      {"revenue_code": "0300", "hcpcs": "85025", "units": 1, "billed_charges": 2180.00}
    ]
  }'

Sample response

{
  "reference_id": null,
  "claim_priced": true,
  "error_message": null,
  "npi": "1234567890",
  "provider_name": "EXAMPLE MEDICAL CENTER",
  "ccn": "450000",
  "hospital_class": "Urban",
  "area_type": "urban",
  "high_volume_provider": false,
  "date_of_service": "2026-04-16",
  "emergency": false,
  "child_patient_used": null,
  "type_of_bill": "131",
  "pricing_path": "day_surgery",
  "claim_total": "6450.90",
  "total_billed_charges": "70280.00",
  "total_lines": 3,
  "lines_priced": 3,
  "lines": [
    {
      "line": 1,
      "revenue_code": "360",
      "hcpcs": "33208",
      "modifier": null,
      "units": 1,
      "service_date": "2026-04-16",
      "billed_charges": "45200.00",
      "rate_found": true,
      "pricing_bucket": "asc_hasc_fee_schedule",
      "bundled": false,
      "allowed_amount": "6450.90",
      "hcpcs_description": null,
      "calculation_method": "$6,450.90 (ASC/HASC fee schedule): highest-rated surgical procedure; pays the day-surgery global fee"
    },
    {
      "line": 2,
      "revenue_code": "278",
      "hcpcs": "C1785",
      "modifier": null,
      "units": 1,
      "service_date": "2026-04-16",
      "billed_charges": "22900.00",
      "rate_found": true,
      "pricing_bucket": "bundled",
      "bundled": true,
      "allowed_amount": "0.00",
      "hcpcs_description": "PACEMAKER, DUAL CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)",
      "calculation_method": "$0.00: bundled into the day-surgery global payment (implantable device; not on the separately-payable exception list)"
    },
    {
      "line": 3,
      "revenue_code": "300",
      "hcpcs": "85025",
      "modifier": null,
      "units": 1,
      "service_date": "2026-04-16",
      "billed_charges": "2180.00",
      "rate_found": true,
      "pricing_bucket": "bundled",
      "bundled": true,
      "allowed_amount": "0.00",
      "hcpcs_description": null,
      "calculation_method": "$0.00: bundled into the day-surgery global payment (service provided in conjunction with the surgery)"
    }
  ],
  "claim_calculation": "Day surgery (scheduled): highest-rated surgical procedure 33208 pays $6,450.90 (ASC/HASC fee schedule); 2 other lines bundled to $0 per the global payment rule (TMPPM 2.11 §6.4.2.1). Claim total = $6,450.90.",
  "rules_applied": [
    {
      "rule": "day_surgery_global",
      "winning_line": 1,
      "winning_code": "33208",
      "fee": "6450.90",
      "bundled_count": 2,
      "separately_paid_devices": 0,
      "high_volume_uplift": false
    }
  ],
  "chirp_adjustments": {
    "STAR": {
      "outpatient_rate_increase": "2.3200",
      "chirp_multiplier": "3.3200",
      "adjusted_claim_total": "21416.99",
      "calculation": "$6,450.90 x (1 + 232.0%) = $21,416.99"
    },
    "STAR_PLUS": {
      "outpatient_rate_increase": "2.3200",
      "chirp_multiplier": "3.3200",
      "adjusted_claim_total": "21416.99",
      "calculation": "$6,450.90 x (1 + 232.0%) = $21,416.99"
    },
    "STAR_KIDS": null
  },
  "flags": [
    {
      "code": "DEVICE_BUNDLED",
      "line": 2,
      "message": "Device C1785 ($22,900.00 billed) is bundled into the day-surgery global payment. TMPPM pays separately only equipment with its own ASC/HASC fee (e.g., implantable infusion pumps E0782/E0783) per §6.2.9/§6.2.11."
    }
  ],
  "effective_start_date": "2026-04-01",
  "effective_end_date": null
}

GET/tx/inpatient/rate

Texas Inpatient Claims

Look up a Texas Medicaid APR-DRG inpatient payment rate, with transfer adjustments, day and cost outlier pricing, PPC/PPR penalty reductions, and CHIRP managed care adjustments. The discharge date determines the effective rate period.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	APR-DRG code (e.g., 140 or 140-2).
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	TPI: Texas Provider Identifier.
`ccn`1 required	string	CMS Certification Number (exact match).
`provider_name`1 required	string	Hospital name (partial match).
`discharge_date`	string	Discharge date (MM/DD/YYYY or YYYY-MM-DD). Defaults to today. Texas uses the discharge date (not admission date) to determine which rate period applies.
`transfer_claim`	boolean	Transfer claim. Discharge status 02 (transferred to another facility).
`child_patient`	boolean	True if patient is under 21 years of age. Defaults to false (adult).
`length_of_stay`	integer	Length of stay in days. Required for transfers. Defaults to mean LOS.
`total_charges`	decimal	Total charges for outlier calc and lesser-of rule.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	TPI: Texas Provider Identifier.
`provider_name`	string	Provider name.
`hospital_class`	string	Hospital classification. Values: Urban, Rural, Childrens, STATE OWNED TEACHING.
`ccn`	string	CMS Certification Number.
`street_address`	string	Hospital street address.
`city`	string	Hospital city.
`county`	string	Hospital county.
`zip_code`	string	Hospital ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system: APR-DRG.
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`apr_drg_code`	string	Base DRG code.
`soi`	integer	Severity of Illness (1–4).
`relative_weight`	decimal	DRG relative weight.
`mean_los`	decimal	Mean length of stay.
`is_delivery_drg`	boolean	Whether this is a delivery-related DRG.
`inpatient_sda`	decimal	Hospital Final SDA.
`delivery_sda`	decimal	Delivery SDA (Rural/Children's only).
`sda_used`	decimal	SDA used in this calculation.
`base_payment`	decimal	Base payment: SDA × relative_weight.
`transfer_adjustment_applied`	boolean	Whether transfer adjustment was applied.
`transfer_per_diem`	decimal	Per-diem used for the transfer calculation: base_payment / mean_los, rounded to cents before multiplying by length_of_stay_used. Populated only when a transfer adjustment was applied.
`transfer_adjusted_amount`	decimal	Payment after transfer adjustment.
`outlier_adjustment_applied`	boolean	Whether outlier was applied.
`outlier_amount`	decimal	Outlier adjustment amount.
`outlier_type`	string	Type of outlier applied. Values: day_outlier, cost_outlier.
`outlier_adjusted_amount`	decimal	Running payment after the outlier was added, before the charge cap and any PPC/PPR reduction. Populated only when an outlier adjustment was applied.
`estimated_cost`	decimal	Estimated cost for cost outlier calc.
`cost_outlier_threshold`	decimal	Cost outlier threshold.
`day_outlier_threshold`	integer	Day outlier threshold.
`marginal_cost_pct`	float	Marginal cost percentage (0.60).
`outlier_reduction_factor`	float	Outlier reduction factor by hospital class.
`inpatient_rcc`	float	Hospital inpatient cost-to-charge ratio.
`universal_mean`	decimal	Universal mean cost for cost outlier threshold.
`charge_cap_applied`	boolean	Whether lesser-of rule reduced payment.
`ppc_pct_applied`	decimal	Hospital-specific PPC penalty.
`ppr_pct_applied`	decimal	Hospital-specific PPR penalty.
`ppc_ppr_adjusted_amount`	decimal	Payment after PPC/PPR reduction.
`length_of_stay_used`	integer	LOS used in calculation.
`total_charges_used`	decimal	Total charges used.
`total_charges_source`	string	Source of charges used. Values: actual, estimated.
`chirp_adjustments`	object	CHIRP IP adjustment per program (STAR, STAR_PLUS, STAR_KIDS). Each contains inpatient_rate_increase, chirp_multiplier, and adjusted_payment.
`discharge_date_used`	date	The discharge date the rate was priced against, echoed from the request. When you omit discharge_date, this returns the server default (today), so the resolved date is always visible.
`child_patient_used`	boolean	Echo of child_patient. True when submitted as true; null otherwise.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/tx/inpatient/rate?\
  billing_code=140-2&\
  npi=1234567890" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1234567890",
    "state_provider_id": "000001",
    "provider_name": "TEXAS GENERAL HOSPITAL",
    "hospital_class": "Urban",
    "ccn": "450001",
    "street_address": "1000 MEDICAL CENTER BLVD",
    "city": "HOUSTON",
    "county": "HARRIS",
    "zip_code": "77030",
    "billing_code": "140-2",
    "billing_code_type": "APR-DRG",
    "payment_rate": "8245.30",
    "payment_rate_type": "claim",
    "calculation_method": "SDA ($8,962.28) × Weight (0.9200) = $8,245.30 (Estimated Payment)",
    "apr_drg_code": "140",
    "soi": 2,
    "relative_weight": "0.9200",
    "mean_los": "3.80",
    "is_delivery_drg": false,
    "inpatient_sda": "8962.28",
    "delivery_sda": null,
    "sda_used": "8962.28",
    "base_payment": "8245.30",
    "transfer_adjustment_applied": false,
    "transfer_per_diem": null,
    "transfer_adjusted_amount": null,
    "outlier_adjustment_applied": false,
    "outlier_amount": null,
    "outlier_type": null,
    "outlier_adjusted_amount": null,
    "estimated_cost": null,
    "cost_outlier_threshold": null,
    "day_outlier_threshold": null,
    "marginal_cost_pct": 0.6,
    "outlier_reduction_factor": 0.9,
    "inpatient_rcc": 0.35,
    "universal_mean": "12500.00",
    "charge_cap_applied": false,
    "ppc_pct_applied": "0.0000",
    "ppr_pct_applied": "0.0000",
    "ppc_ppr_adjusted_amount": "8245.30",
    "length_of_stay_used": 4,
    "total_charges_used": null,
    "total_charges_source": null,
    "chirp_adjustments": {
      "STAR": {
        "inpatient_rate_increase": "0.57",
        "chirp_multiplier": "1.57",
        "adjusted_payment": "12945.12"
      },
      "STAR_PLUS": {
        "inpatient_rate_increase": "0.57",
        "chirp_multiplier": "1.57",
        "adjusted_payment": "12945.12"
      },
      "STAR_KIDS": {
        "inpatient_rate_increase": "0.57",
        "chirp_multiplier": "1.57",
        "adjusted_payment": "12945.12"
      }
    },
    "discharge_date_used": "2026-08-01",
    "child_patient_used": null,
    "effective_start_date": "2024-09-01",
    "effective_end_date": null
  }
]

POST/tx/inpatient/rate/batch

Look up multiple TX inpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "140-2",
      "npi": "1234567890"
    },
    {
      "billing_code": "560-1",
      "npi": "9876543210",
      "length_of_stay": 4,
      "total_charges": "62000",
      "child_patient": true
    }
  ]
}

GET/tx/providers/search

Texas Provider Search

Search for Texas Medicaid providers by NPI, TPI, CCN, name, or location. Returns provider details including hospital classification and rate availability.

Parameters

Name	Type	Description
`npi`	string	National Provider Identifier (10 digits).
`state_provider_id`	string	TPI: Texas Provider Identifier.
`ccn`	string	CMS Certification Number.
`provider_name`	string	Provider name (partial match, min 2 characters).
`city`	string	City (partial match).
`zip_code`	string	ZIP code (exact match).
`county`	string	County (partial match).
`taxonomy`	string	Taxonomy code filter.
`provider_type`	string	State Rates provider classification. Values: PHYSICIAN, HOSPITAL, ASC_HASC, HOSPITAL_OP_IMAGING, CLINICAL_LABORATORY, OUTPATIENT_BEHAVIORAL_HEALTH, AMBULANCE.
`hospital_class`	string	Hospital classification. Values: Urban, Rural, Childrens, STATE OWNED TEACHING.
`limit`	integer	Max results (default 100, max 1000).

Returns

Field	Type	Description
`providers`	array	List of matching providers.
↳`npi`	string	Provider NPI.
↳`state_provider_id`	string	TPI: Texas Provider Identifier.
↳`provider_name`	string	Provider name.
↳`provider_type`	string	State Rates provider classification.
↳`provider_type_label`	string	Human-readable label for the State Rates provider classification.
↳`entity_type`	string	Individual or Organization.
↳`primary_taxonomy`	string	Primary taxonomy code.
↳`street_address`	string	Street address.
↳`city`	string	City.
↳`state`	string	State.
↳`zip_code`	string	ZIP code.
↳`county`	string	County.
↳`ccn`	string	CMS Certification Number (hospitals only).
↳`hospital_class`	string	Hospital classification (hospitals only). Values: Urban, Rural, Childrens, STATE OWNED TEACHING.
↳`op_rates`	boolean	Has outpatient rates.
↳`ip_rates`	boolean	Has inpatient rates.
`total_results`	integer	Total results found.
`limit_applied`	integer	Limit applied.

Request

curl "https://staterates.health/api/v1/tx/providers/search?\
  provider_name=memorial&\
  city=houston" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

{
  "providers": [
    {
      "npi": "1234567890",
      "state_provider_id": "000001",
      "provider_name": "MEMORIAL HERMANN HOSPITAL",
      "provider_type": "HOSPITAL",
      "provider_type_label": "Hospital",
      "entity_type": "Organization",
      "primary_taxonomy": "282N00000X",
      "street_address": "6411 FANNIN ST",
      "city": "HOUSTON",
      "state": "TX",
      "zip_code": "77030",
      "county": "HARRIS",
      "ccn": "450001",
      "hospital_class": "Urban",
      "op_rates": true,
      "ip_rates": true
    }
  ],
  "total_results": 1,
  "limit_applied": 100
}

GET/wv/outpatient/rate

West Virginia Outpatient Rates

Look up a West Virginia Medicaid outpatient rate. Pricing routes by provider type across WV's outpatient fee schedules: RBRVS, clinical lab, emergency department, outpatient surgery, and ASC.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	HCPCS/CPT code (e.g., 99213).
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	WV Medicaid Provider ID (e.g., '0001258000'). Published for hospitals only; other provider types have none.
`provider_name`1 required	string	Provider name (partial match, case-insensitive). Returns rates for all matches.
`provider_type`	string	State Rates provider classification. Values: HOSPITAL, PHYSICIAN, ASC, CLINICAL_LABORATORY, IMAGING_CENTER. If omitted, resolved from the provider's NPI.
`modifier`	string	Modifier. Values: 26 (Professional Component), TC (Technical Component), QW (CLIA-waived lab). Matched exactly to a published rate row. For hospital/imaging-center imaging, the TC row is auto-selected when no modifier is passed. RBRVS only.
`place_of_service`	string	Place of service (RBRVS only). Values: facility, non_facility. If omitted, the non_facility rate is returned. No effect on lab / ED / surgery / ASC paths.
`units`	integer	Number of 15-minute time units billed. Applies to outpatient surgery codes only, capped at the code's maximum payable units. Ignored for other code types. Defaults to 1.
`date_of_service`	string	Date of service (MM/DD/YYYY or YYYY-MM-DD). Defaults to today. Selects the fee schedule in effect on this date.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Provider NPI.
`state_provider_id`	string	WV Medicaid Provider ID (hospitals only; NULL for non-hospital providers).
`provider_name`	string	Provider name.
`provider_type`	string	State Rates provider classification.
`provider_type_label`	string	Human-readable provider type label.
`hospital_class`	string	Hospital peer-group classification (HOSPITAL only). Values: RRC, SCH, ACH, MDH and combinations (e.g., 'SCH/RRC').
`primary_taxonomy_code`	string	NPPES primary taxonomy code (non-hospital providers).
`primary_taxonomy_display_name`	string	NPPES primary taxonomy display name.
`street_address`	string	Provider street address.
`city`	string	Provider city.
`county`	string	Provider county.
`state`	string	Provider state (always 'WV').
`zip_code`	string	Provider ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system. Values: HCPCS, APR-DRG.
`billing_code_description`	string	Human-readable code description. Populated for HCPCS Level II codes (CMS-sourced); null for CPT (HCPCS Level I) and EAPG/APG codes, whose descriptions are licensed content.
`modifier`	string	Modifier on the matched row (e.g., '26', 'TC', 'QW'). Sourced from the row, not the request input.
`modifier_adjustment`	decimal	Multiplier applied to base_rate to derive payment_rate on a derived modifier row (e.g., 26/TC split). NULL when the rate is published as-is.
`base_rate`	decimal	Source fee-schedule rate before any modifier adjustment. When modifier_adjustment is populated, payment_rate = base_rate × modifier_adjustment; otherwise base_rate equals payment_rate.
`place_of_service`	string	Place of service on the matched row (RBRVS only).
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`service_category`	string	Which fee schedule priced the code. Values: physician_rbrvs, clinical_lab, emergency_department, op_surgery, asc.
`cbsa`	string	CBSA used to select the ASC rate tab (ASC only), resolved from the provider's county.
`per_unit_rate`	decimal	Per-15-minute-unit rate before the units multiplier (op_surgery only).
`units_used`	integer	Units applied to the per-unit rate (op_surgery only), after capping at max_units.
`max_units`	integer	Maximum payable 15-minute units for this surgery code (op_surgery only).
`unit_max_reimbursement`	decimal	Ceiling reimbursement at max_units (op_surgery only, context).
`is_manually_priced`	boolean	TRUE when the code is priced case-by-case (carrier/manual/unlisted/cost-invoice). payment_rate NULL with an explanatory message.
`is_packaged`	boolean	TRUE for ASC packaged rows: covered, no separate payment. payment_rate $0.00 with an explanatory message.
`date_of_service_used`	date	The date of service the rate was priced against, echoed from the request. When you omit date_of_service, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/wv/outpatient/rate?\
  billing_code=99213&\
  npi=1063737765" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1063737765",
    "state_provider_id": null,
    "provider_name": "WEST VIRGINIA PHYSICIANS GROUP",
    "provider_type": "PHYSICIAN",
    "provider_type_label": "Physician",
    "hospital_class": null,
    "primary_taxonomy_code": "207R00000X",
    "primary_taxonomy_display_name": "Internal Medicine",
    "street_address": "100 MAIN ST",
    "city": "HUNTINGTON",
    "county": "CABELL",
    "state": "WV",
    "zip_code": "25701",
    "billing_code": "99213",
    "billing_code_type": "HCPCS",
    "billing_code_description": null,
    "modifier": null,
    "modifier_adjustment": null,
    "base_rate": "63.48",
    "place_of_service": "non_facility",
    "payment_rate": "63.48",
    "payment_rate_type": "fee_schedule",
    "calculation_method": "RBRVS Fee Schedule (Non-Facility) = $63.48",
    "service_category": "physician_rbrvs",
    "cbsa": null,
    "per_unit_rate": null,
    "units_used": null,
    "max_units": null,
    "unit_max_reimbursement": null,
    "is_manually_priced": false,
    "is_packaged": false,
    "date_of_service_used": "2026-08-01",
    "effective_start_date": "2026-04-01",
    "effective_end_date": null
  }
]

POST/wv/outpatient/rate/batch

Look up multiple WV outpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "99213",
      "npi": "1063737765"
    },
    {
      "billing_code": "71046",
      "npi": "1841271459"
    }
  ]
}

GET/wv/inpatient/rate

West Virginia Inpatient Rates

Look up a West Virginia Medicaid MS-DRG inpatient payment rate, with adjustments for cost outliers, transfer per-diem pricing, and same-day and next-day claims. The discharge date determines the effective rate year.

Parameters

Name	Type	Description
`reference_id`	string	A correlation ID (max 128 chars) echoed back unchanged in the response, so you can match each rate result to the source claim or account in your system. Do NOT pass PHI in this field. Use a hashed value, UUID, or per-batch synthetic ID; never raw account numbers, MRNs, or claim numbers from your billing or EHR system. State Rates does not log, persist, or inspect this value; it is stripped from request logs and error tracking.
`billing_code`required	string	MS-DRG code (e.g., '470', 'N90').
`npi`1 required	string	National Provider Identifier (10 digits).
`state_provider_id`1 required	string	WV Medicaid Provider ID for the hospital (e.g., '0001258000').
`provider_name`1 required	string	Hospital name (partial match, case-insensitive).
`discharge_date`	string	Discharge date (MM/DD/YYYY or YYYY-MM-DD). Selects the rate year. Defaults to today.
`length_of_stay`	integer	Length of stay in days. Required to price transfer claims correctly: the graduated per-diem is paid per day, and when omitted the calculation assumes a 1-day stay.
`transfer_claim`	boolean	Transfer claim. Discharge status 02 (transferred to another acute-care facility).
`same_day_claim`	boolean	Same-day or next-day claim. Check when admission and discharge fall on the same or next day. Requires total charges.
`total_charges`	decimal	Total covered charges (UB-04 FL47). Used for the cost-outlier and same-day calculations.
`room_and_board_charges`	decimal	Room and board charges: the sum billed under room-and-board revenue codes. Used on the same-day path.
`observation_charges`	decimal	Observation charges: the sum billed under the observation revenue code (0762). Used on the same-day path.
`observation_hours`	decimal	The number of hours the patient was in observation status. Used on the same-day path.

Returns

Field	Type	Description
`reference_id`	string	Echo of the `reference_id` from the request (null if not sent). Use this to match each result back to your source claim or account.
`rate_found`	boolean	Whether a rate was found.
`error_message`	string	Error details if rate not found. Null on success.
`npi`	string	Hospital NPI.
`state_provider_id`	string	WV Medicaid Provider ID.
`provider_name`	string	Hospital name.
`provider_type`	string	Provider type (HOSPITAL).
`provider_type_label`	string	Human-readable provider type label.
`hospital_class`	string	Hospital peer-group classification. Values: RRC, SCH, ACH, MDH and combinations.
`ccn`	string	Medicare CCN.
`market_area`	string	WV market area (1–6).
`street_address`	string	Hospital street address.
`city`	string	Hospital city.
`county`	string	Hospital county.
`state`	string	Hospital state.
`zip_code`	string	Hospital ZIP code.
`billing_code`	string	Billing code submitted.
`billing_code_type`	string	Code system. Values: HCPCS, APR-DRG.
`billing_code_description`	string	Human-readable code description. Populated for HCPCS Level II codes (CMS-sourced); null for CPT (HCPCS Level I) and EAPG/APG codes, whose descriptions are licensed content.
`drg_code_used`	string	DRG actually priced. Differs from billing_code when the neonatal remap applies (789–794 → N89–N94 at the four Level III hospitals).
`neonatal_remap_applied`	boolean	TRUE when billing_code 789–794 was remapped to an N89–N94 Level III neonatal DRG for this hospital.
`wv_specific_drg`	boolean	TRUE for WV-specific Level III neonatal pseudo-DRGs (N89–N94).
`grouper_version`	string	Medicare MS-DRG grouper version for the rate year (e.g., 'V43').
`payment_rate`	decimal	Payment rate in dollars.
`payment_rate_type`	string	Rate type. Values: fee_schedule, percent_of_charges, manually_priced, claim, per_diem.
`calculation_method`	string	Human-readable calculation formula with actual values.
`drg_weight`	decimal	WV-specific DRG relative weight.
`alos`	decimal	Average length of stay for the DRG (drives the transfer per-diem).
`base_amount`	decimal	Provider Price Factor: (WV Std Cost × (1 + IME) × Wage Index + Std Cap) × 1.025.
`base_payment`	decimal	Base DRG payment = base_amount × drg_weight.
`wv_std_cost`	decimal	Hospital WV standardized cost amount.
`std_cap_amt`	decimal	Hospital standardized capital amount.
`ime_adjustment`	decimal	Indirect medical education adjustment.
`wage_index_gaf`	decimal	Provider wage index / geographic adjustment factor.
`cost_charge_ratio`	decimal	Hospital cost-to-charge ratio.
`outlier_adjustment_applied`	boolean	TRUE when a cost-outlier add-on was applied.
`outlier_amount`	decimal	IME/tax-adjusted cost-outlier add-on included in the payment.
`outlier_threshold`	decimal	Cost-outlier threshold = (WV Std Cost × weight + $112,918) × Wage Index.
`estimated_cost`	decimal	Estimated cost = total charges × adjusted CCR.
`adjusted_cost_charge_ratio`	decimal	CCR ÷ (1 + IME), used to estimate cost for the outlier.
`total_charges_used`	decimal	Total charges used in the outlier / same-day calculation.
`outlier_note`	string	Set when the cost outlier could not be computed; e.g., discharges before 2025-10-01 (RY2026), where the historical outlier constants are not published.
`transfer_adjustment_applied`	boolean	TRUE when transfer per-diem pricing was applied.
`transfer_payment_amount`	decimal	Graduated per-diem transfer payment (before the lesser-of comparison).
`per_diem_amount`	decimal	Per-diem = (base + outlier) ÷ ALOS.
`first_day_per_diem`	decimal	First-day per-diem = 3 × per-diem.
`length_of_stay_used`	integer	Days used for the transfer per-diem.
`transfer_full_drg_exception`	boolean	TRUE when the transfer full-DRG exception applied (neonate transfer/death or burn DRG): the full DRG is paid despite the transfer.
`same_day_applied`	boolean	TRUE when same-day/next-day lesser-of pricing was applied.
`same_day_payment_amount`	decimal	Same-day payment = ancillary × CCR + $10 × obs hours + $245 (before the lesser-of comparison).
`total_ancillary_charges`	decimal	Total charges − room & board − observation charges (same-day path).
`room_and_board_used`	decimal	Room & board charges used in the same-day calculation (subtracted from total charges to get ancillary).
`observation_charges_used`	decimal	Observation charges used in the same-day calculation (subtracted from total charges to get ancillary).
`observation_hours_used`	decimal	Observation hours used in the same-day calculation.
`same_day_note`	string	Set when the same-day path could not be computed; e.g., discharges before 2025-10-01 (RY2026).
`discharge_date_used`	date	The discharge date the rate was priced against, echoed from the request. When you omit discharge_date, this returns the server default (today), so the resolved date is always visible.
`effective_start_date`	date	Rate period start date.
`effective_end_date`	date	Rate period end date. Null if currently active.

Request

curl "https://staterates.health/api/v1/wv/inpatient/rate?\
  billing_code=470&\
  npi=1841271459&\
  discharge_date=2025-11-15" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

[
  {
    "rate_found": true,
    "error_message": null,
    "npi": "1841271459",
    "state_provider_id": "0001258000",
    "provider_name": "WEST VIRGINIA UNIVERSITY HOSPITALS",
    "provider_type": "HOSPITAL",
    "provider_type_label": "Hospital",
    "hospital_class": "RRC",
    "ccn": "510001",
    "market_area": "6",
    "street_address": "1 MEDICAL CENTER DR",
    "city": "MORGANTOWN",
    "county": "MONONGALIA",
    "state": "WV",
    "zip_code": "26506",
    "billing_code": "470",
    "billing_code_type": "MS-DRG",
    "billing_code_description": "MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC",
    "drg_code_used": "470",
    "neonatal_remap_applied": false,
    "wv_specific_drg": false,
    "grouper_version": "V43",
    "payment_rate": "11188.66",
    "payment_rate_type": "claim",
    "calculation_method": "$5,402.02 (Provider Price Factor) × 2.0712 (DRG Weight) = $11,188.66 (Total Payment)",
    "drg_weight": "2.0712",
    "alos": "1.30",
    "base_amount": "5402.02",
    "base_payment": "11188.66",
    "wv_std_cost": "4211.47",
    "std_cap_amt": "436.66",
    "ime_adjustment": "0.165320",
    "wage_index_gaf": "0.9849",
    "cost_charge_ratio": "0.2590",
    "outlier_adjustment_applied": false,
    "outlier_amount": null,
    "outlier_threshold": null,
    "estimated_cost": null,
    "adjusted_cost_charge_ratio": null,
    "total_charges_used": null,
    "outlier_note": null,
    "transfer_adjustment_applied": false,
    "transfer_payment_amount": null,
    "per_diem_amount": null,
    "first_day_per_diem": null,
    "length_of_stay_used": null,
    "transfer_full_drg_exception": false,
    "same_day_applied": false,
    "same_day_payment_amount": null,
    "total_ancillary_charges": null,
    "room_and_board_used": null,
    "observation_charges_used": null,
    "observation_hours_used": null,
    "same_day_note": null,
    "discharge_date_used": "2025-11-15",
    "effective_start_date": "2025-10-01",
    "effective_end_date": null
  }
]

POST/wv/inpatient/rate/batch

Look up multiple WV inpatient rates in a single POST request. Maximum 1,000 lookups per batch.

Batch request

{
  "requests": [
    {
      "billing_code": "470",
      "npi": "1841271459",
      "discharge_date": "2025-11-15"
    },
    {
      "billing_code": "470",
      "npi": "1841271459",
      "discharge_date": "2025-11-15",
      "total_charges": "900000",
      "transfer_claim": false
    }
  ]
}

GET/wv/providers/search

West Virginia Provider Search

Search for West Virginia Medicaid providers by NPI, WV Medicaid Provider ID (hospitals only), name, location, taxonomy, provider type, or hospital class. Returns provider details with rate availability.

Parameters

Name	Type	Description
`npi`	string	National Provider Identifier (10 digits).
`state_provider_id`	string	WV Medicaid Provider ID (hospitals only).
`provider_name`	string	Provider name (partial match, case-insensitive).
`city`	string	City (partial match).
`county`	string	County (partial match).
`zip_code`	string	ZIP code (exact match).
`taxonomy`	string	NUCC taxonomy display name (partial match, non-hospital).
`provider_type`	string	State Rates provider classification. Values: HOSPITAL, PHYSICIAN, ASC, CLINICAL_LABORATORY, IMAGING_CENTER.
`hospital_class`	string	Hospital classification filter (HOSPITAL only), matched exactly. Values: ACH, RRC, SCH, MDH, EACH/RRC, MDH/RRC, SCH/RRC.
`limit`	integer	Max results (default 100, max 1000).

Returns

Field	Type	Description
`providers`	array	List of matching providers.
↳`npi`	string	Provider NPI.
↳`state_provider_id`	string	WV Medicaid Provider ID (hospitals only; NULL for non-hospital providers).
↳`provider_name`	string	Provider name.
↳`provider_type`	string	State Rates provider classification.
↳`provider_type_label`	string	Human-readable provider type label.
↳`entity_type`	string	Individual or Organization (always 'Organization' for HOSPITAL).
↳`primary_taxonomy`	string	NPPES primary taxonomy display name (non-hospital).
↳`hospital_class`	string	Hospital peer-group classification (HOSPITAL only). Values: RRC, SCH, ACH, MDH and combinations.
↳`street_address`	string	Street address.
↳`city`	string	City.
↳`county`	string	County.
↳`state`	string	State.
↳`zip_code`	string	ZIP code.
↳`op_rates`	boolean	Has outpatient rates.
↳`ip_rates`	boolean	Has inpatient rates.
`total_results`	integer	Total results found.
`limit_applied`	integer	Limit applied.

Request

curl "https://staterates.health/api/v1/wv/providers/search?\
  provider_name=huntington&\
  provider_type=HOSPITAL" \
  -H "Authorization: Bearer YOUR_API_KEY"

Sample response

{
  "providers": [
    {
      "npi": "1073518007",
      "state_provider_id": "0001144000",
      "provider_name": "CABELL HUNTINGTON HOSPITAL",
      "provider_type": "HOSPITAL",
      "provider_type_label": "Hospital",
      "entity_type": "Organization",
      "primary_taxonomy": null,
      "hospital_class": "RRC",
      "street_address": "1340 HAL GREER BLVD",
      "city": "HUNTINGTON",
      "county": "CABELL",
      "state": "WV",
      "zip_code": "25701",
      "op_rates": true,
      "ip_rates": true
    }
  ],
  "total_results": 1,
  "limit_applied": 100
}

Errors

Status	Common code	Meaning
400	api_key_in_query	Key sent in a URL query string. Put it in the Authorization header.
401	missing_api_key	No Authorization header or the Bearer scheme is missing.
401	invalid_api_key	Key is unknown, revoked, or past its expiry.
403	state_not_enabled	Your key isn't scoped to the state you called. Email support to add it.
404	—	Endpoint path doesn't exist. Check the URL against the reference above.
422	—	Request parsed but violated a schema rule (e.g. batch over 1000 items). See `detail` for field-level errors.
429	token_bucket_exceeded	Token bucket exhausted for the current billing period, or per-key burst limit tripped (burst 429s have no JSON body). See Rate Limits.
500	—	Our bug. Don't retry blindly. Email support with the timestamp.
502	—	API briefly unreachable (usually a deploy restart). Safe to retry after ~5s.

Error response

{
  "detail": {
    "error": {
      "type": "authentication_error",
      "code": "invalid_api_key",
      "message": "Invalid or revoked API key"
    }
  }
}

Rate Limits & Quotas

Two limits, both return 429:

Short-term throttle: 1 request per second per key, with bursts up to 30. Go over and you'll get a 429; wait a second and try again.
Token bucket: each org gets a contract-sized token bucket that pools across every state on the key. Costs per call: 1 token per inpatient rate, 0.25 tokens per outpatient line item,1 token per whole outpatient claim,0 tokens for provider search. A 500-IP-claim batch costs 500 tokens; the same shape of OP batch costs 125. When the bucket runs out you'll get a 429 with a JSON body showing exactly where you stand.

Every metered 2xx and 429 response includes these headers so you can monitor headroom:

X-RateLimit-Reset is the timestamp your current bucket expires. Provider search responses carry no rate-limit headers (the call is free).

If a batch would push you over the bucket, the entire batch is rejected; no partial fulfillment. The requested / remaining / resets_at fields let you split the batch and retry precisely.

Rate-limit headers

X-RateLimit-Limit:     1000
X-RateLimit-Remaining: 873.75
X-RateLimit-Reset:     2026-07-01T00:00:00Z

429 token-bucket body

{
  "detail": {
    "error": {
      "type": "rate_limit_error",
      "code": "token_bucket_exceeded",
      "message": "Token bucket exhausted for this billing period",
      "state": "TX",
      "requested": "125.00",
      "remaining": "73.50",
      "resets_at": "2026-07-01T00:00:00+00:00"
    }
  }
}