Concept explainer
Tariffs and rate cards
Explains how tariffs and rate cards set the price of an item for a given payer or scheme, and how several may apply at once.
A tariff sets the price of an item for a given payer or scheme. Where the charge master holds a base price, a rate card carries the price a particular payer has agreed, and several may apply to one charge at once. This page sets out rate cards, tiers and packages, and how they resolve together.
Rate cards and tiers
A rate card is a named set of prices for the charge master items. A site keeps one active rate card at a time, and activating a new one archives the card it replaces, so exactly one is in force.
Within a card, an item can carry several tier prices. A payer maps to a tier, and a charge takes the price in that payer's tier. Where a payer holds a contracted tier with no price set for an item, the charge is held for review so a biller can settle the rate. Where a payer maps to no rate card at all, the hospital's own base rate applies.
Packages
A package is a fixed-price bundle, common for surgery and for scheme care. The package carries one price for a set of included items. Where care runs beyond the bundle, the overrun follows the package's rule: billed as fee-for-service excess, held to a cap, or disallowed. The bundle price plus any excess equals the total billable, so an item inside the bundle is counted once.
packagePrice integer Required | The fixed bundle price. |
includedItems list Required | The charge master items the bundle covers. |
overrunRule string Required | How care beyond the bundle is treated: excess, capped or disallowed. |
implantCeiling integer | A ceiling on implant cost inside the bundle. |
How several apply at once
A single charge can meet a base rate, a payer tier and a package at the same time. They resolve in a fixed order rather than competing, and each leaves a recorded step. The base rate comes first, the payer's tariff tier replaces it, and a package or a scheme rate overrides where it applies.
| Base rate | Tariff tier | Package | |
|---|---|---|---|
| Comes from the charge master | Present | Absent | Absent |
| Set by a payer or scheme agreement | Absent | Present | Present |
| Prices a single item | Present | Present | Absent |
| Prices a bundle of items | Absent | Absent | Present |
Effective dating
Rate cards are effective-dated in the same way as the charge master. The price cells carry their own valid periods, so a retroactive rate correction resolves against the date a charge was raised. A charge holds the rate that was in force on its service date, and a card activated later leaves earlier charges as they stood.
Read how these rates combine step by step in the pricing waterfall.