Every claim, routed to its Medicare payment system
Bill type and provider type decide which system a claim belongs to. Each one has a published CMS source for its grouping and its rate, and every one runs on the same pass. Ordered by dollars in a typical Medicare Advantage population.
Two systems are paid from a rate set for the individual provider and sent to it in a letter: rural health clinics and critical access hospitals. No CMS file publishes those rates. They are loaded as a table, and claims priced without one are flagged on the mart.
The priced claims mart
One row per claim: expected Medicare payment, what was paid, the difference and its reason. Twelve months of a synthetic population, read the way a dashboard on the mart reads it.
Which adjustments count as Medicare is a contract definition, so each one is a switch rather than an assumption.
One claim, traced
A synthetic claim followed to its price. Each step names the CMS program or file that performed it.
Look up a rate
Four public hospitals, with the factors the public provider file carries for them and what the CMS pricers pay them for common groups. Pick one.
The base rate is a lookup. The claim price is not: transfers, outliers and line packaging depend on the claim, which is why the engine runs on claims and not on a rate sheet.