Synthetic General Hospital

Summary

25 rates in the price file need allowed amounts because they're expressed as a percentage or an algorithm. Percentry calculated 15 from 835 remittances and confirmed that 2 had none in the lookback window.

• Passed Self-check: the results pass Percentry's price file checks for allowed amounts.
• Passed Completed price file: written in the original's format, read back value by value, and checked.
• To resolve 8 rates need a mapping, a code, or a check of their remittances before they can be calculated; see Needs attention.

15 rates the original file reported with a count of "0" have remittances in the lookback window. The completed price file replaces those counts with the calculated counts and percentiles, and takes the original's zero-count explanation out of the notes on 15 rates (see Checks).

Results by rate

Allowed amounts in dollars. The count uses CMS's encoding: "0", "1 through 10", or the number from 11 up. It counts payments, except that each unit of a time-based code counts once (CMS's FAQ).

Needs attention

How payments matched the price file

Every payment dollar is accounted for: it counted toward a rate, matched only dollar rates (which don't need allowed amounts), or matched nothing. Payments are service lines and DRG claims; other claim totals would count their lines twice.

How the counted payments' allowed amounts were found

Unmatched dollars by 835 payer and setting

Payments whose code isn't in the price file for the plan, is there only in another setting, whose payer and plan aren't mapped, or whose claim type is unclear. A high share here usually means a mapping gap, not missing payments.

Paid codes the price file doesn't list for the plan

The plan paid for these services, but the price file has no rate for them. Worth checking that the file lists every item and service the hospital is paid for.

Which payments count

13 835 files: 104 remittances, 2,292 claims, and 3,919 service lines, paid 2025-01-15 to 2026-01-10. Provider-level adjustments (PLB), which aren't tied to any service, total $3,110.33 and are left out.

Only each claim's final adjudication counts, paid as primary, to this location, inside the lookback window, with an allowed amount above $0. A paid remittance whose allowed amount can't be derived is kept here, so the rates it reaches show up in Needs attention instead of as zeros. Everything else is set aside, by reason:

Payer and plan mapping

Price files name payers and plans in their own words, which rarely appear in an 835. Percentry suggested each link below from payer IDs, names, and claim filing codes; a person confirmed it or marked the 835 plan to be ignored.

Settings and inputs

Posting date

2026-02-01

Lookback window

12 months by payment (check or EFT) date: 2025-02-01 to 2026-01-31

Location (payee NPI)

1234567893

Claim types

institutional claims only, told apart from professional ones by 835 signals (revenue codes, DRG, MIA, bill types that can't be a place of service): Percentry's reading. Professional claims and professional fee lines (revenue codes 096x–098x) are set aside. Claims with no signal either way, or with signals of both kinds, are left out too, and a rate they would reach is unresolved rather than zero.

Setting

inpatient: bill types 11x; outpatient: 12x, 13x, 85x; set aside: 14x (non-patient lab), 18x (swing bed), 71x (rural health clinic), 72x (renal dialysis), 83x (ASC), and any other bill type. The inpatient and outpatient groups follow Medicare's bill-type designations (Claims Processing Manual ch. 1 §60.4; 12x, inpatient Part B, is outpatient). Using them for the price file's settings, and the bill types set aside, are Percentry's choices. A claim with no bill type is inpatient when it has a DRG or MIA, and otherwise reaches only rates whose setting is "both". DRG rates use only final inpatient bills (frequency 1 or 7). A rate that only set-aside payments would reach is unresolved, not zero.

Allowed amount

the line's AMT*B6 when it passes Percentry's checks; otherwise paid plus deductible, coinsurance and copay, plus the adjustments that belong inside the allowed amount by their signed amounts (penalties and withholds added back; taxes and bonuses taken out), when the line balances and the claim has no claim-level adjustment outside the allowed amount. Sequestration (CO-253) is added back too: Percentry's reading of CMS's definition (the payer's portion plus the patient's), because sequestration cuts the payment after the allowed amount is set. DRG claims: the same over the whole claim, less claim interest only when the claim payment includes it. A payment whose allowed amount can't be found this way isn't counted, and a rate only such payments reach is unresolved, not zero. Reason-code table carc-2026-10-02: Percentry's reading of the X12 835.

Units

for the 139 codes on Percentry's time-based list (its selection from CMS sources), a line's allowed amount is divided by its units and each unit counts as one observation (CMS HPT FAQ, June 26, 2026). Percentry's choices: it divides by the units paid (SVC05), where the FAQ speaks of units performed; only lines whose units are a whole number from 1 to 9,999, and whose per-unit amount is at least a cent, are counted (others leave a rate unresolved if nothing else reaches it); and case-rate rates, claim totals, and rates reached only through a revenue code are never divided. Drugs, accommodation days, and other multi-unit lines count once per line: CMS hasn't said to divide them, so Percentry doesn't.

Percentiles

position ⌊p × n⌋ + 1 in the sorted amounts (1-based, capped at n): the "next highest" observed value. Both the position rule and rounding the percentiles to the cent, half away from zero, are Percentry's choices; CMS gives only the "next highest" rule

Mappings used

confirmed only

Files

Settings hash b8bf6ec19336fc0d2369b3db40370357bd995d28f29f4cb736a0f625d7e97883 covers every setting above and the SHA-256 of every file, so a rerun on the same files with the same settings can be confirmed to match. Allowed-Amount Percentiles 1.0.0+5508589a51fea196cd8e672fa043f1a9a62938fe; generated 2026-10-05 00:14 UTC.

Checks

Self-check

Passed The results pass Percentry's price file checks for allowed amounts: a count on every rate, percentiles unless the count is "0", a note for every "0", valid count formats, positive amounts, percentiles in order, and no percentiles with a zero count.

Completed price file

Passed synthetic-price-file.json (JSON, 13 KB), SHA-256 436d26b80b0fe1e3bf10f257926d54912bce2b4bf113b9cf5253b5bf15f22e94

• 17 rates updated. Everything else is carried over from the original; rates that weren't calculated are left exactly as they were.
• Read back with Percentry's price file readers: every calculated and zero rate carries exactly the values in this report.
• 8 rates Percentry couldn't calculate still carry the original file's count of "0", which these remittances can't confirm. Resolve them before posting (see Needs attention).
• A full price file check finds no remaining allowed-amount problems in the file.

Notes that explained the old zeros

15 rates now have remittances, so the original file's explanation of their count of "0" is no longer true and was taken out. 2 rates still have none; their generic explanation was replaced with Percentry's note naming the payer, plan, location, and dates. Only the zero-count wording is taken out; the rest of each note is kept.

Showing 10 of 17; row-evidence.csv lists every one.