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Medicare Allowed

medicare_allowed
Read-onlyIdempotent

Returns the Medicare allowed amount for ONE billing code (CPT/HCPCS, or an MS-DRG for inpatient) from every Medicare fee schedule that prices it: PFS (professional, national non-facility), OPPS Addendum B (hospital outpatient APC), ASC, CLFS (lab), and IPPS (national DRG amount). Inputs: billing_code (required); optional care_class to pick the setting that fits a site (02_asc, 03_outpatient, 04_urgent_care, 05_imaging, 06_lab, 07_dialysis — the same preference table the care-site price bridge uses for its Medicare floor); optional setting to return one schedule only (PFS_non_facility | OPPS_APC | ASC | CLFS | IPPS_MSDRG_national); optional medicare_year to PIN a schedule vintage (4-digit year; omit it and the LATEST edition held for the chosen schedule is served — an older vintage is never returned unless you pin it); optional limit.

RETURNS a detail payload: value.medicare_year and value.setting state the vintage and schedule actually served; value.summary carries the PREFERRED row for the requested care_class (medicare_allowed, medicare_source, medicare_year, billing_class), the latest year held per schedule (latest_year_by_schedule) and whether the year was pinned or resolved (medicare_year_selection), plus the count of schedules that price the code; value.settings lists EVERY schedule row for the code with what it is (fee_schedule, professional vs facility component, site, national basis, locality_adjusted=false, source_table, medicare_year vintage). Every number is NATIONAL — no GPCI / wage-index localisation is applied, and PFS is the NON-FACILITY (office) professional rate. A code priced on no schedule returns found=false ('not priced on these Medicare schedules', never $0). Reads the latest available edition per schedule (vlada_curated.vw_medicare_benchmark_effective per schedule, so an ASC rate is listed beside the OPPS rate for the same code; the underlying M-2 fact tables are read WHERE is_current).

SOURCE: CMS PFS RVU + conversion factor, OPPS Addendum B, ASC addendum, CLFS, IPPS Table 5 + base rates.

Input Schema

TableJSON Schema
NameRequiredDescriptionDefault
limitNo
settingNo
care_classNo
billing_codeYes
medicare_yearNo

Output Schema

TableJSON Schema
NameRequiredDescriptionDefault
unitNo
as_ofNo
valueYes
sourceYes
statusNocomplete
caveatsNo
failureNo
qualityNo
refusalNo
vintageNoas_restated
audit_idYesUUID; ties to medicare_silver.audit_log row.
signatureNo
tenant_idNoCalling tenant slug, resolved by the binding and stamped via the per-call tenant context. Defaults to the bootstrap 'internal' tenant for local/in-process callers.
timestampYes
confidenceNo
data_as_ofNo
request_idYes
methodologyNo
snapshot_setYes{table_fqn → iceberg_snapshot_id (int64)}. Per M-2 §2.2.
tool_versionYes
response_hashYesSHA-256 of canonicalized form per M-2 §2.4.
result_statusYes
vintage_basisNodefault_unmeasured
as_of_assertedNo
as_of_observedNo
parse_revisionNo
as_of_effectiveNo
freshness_stateNounknown
methodology_eraNo
confidence_basisNo
semantic_versionYes
invariants_appliedNo
finality_confidenceNo
cms_vintage_sequenceYes
parser_artifact_hashYes
methodology_blend_factorsNo
parser_artifact_hash_basisNonot_evaluated

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