DRG Inpatient Payment Calculator

MS-DRG base rate × CMS relative weight, plus day-outlier per diem, priced against your hospital's contracted base rate.

Payer

Inpatient Settings

Plan Type

Contract Year

Grouper Version

Service Date

Lesser of charges

Base Rate$0

Oklahoma Medicaid — Inpatient Settings

SoonerSelect is currently required to pay 100% of this same OHCA fee-for-service schedule under the state's provider rate floor — both tracks price identically today. The track you pick only changes the citation saved on the calculation, in case that floor is narrowed or expires later.

Service Date

Track

Payment won't exceed billed charges

Peer-Group Base Rate$0

Set this hospital's OHCA peer group

OHCA assigns every SoonerCare hospital to one of several peer groups, each with its own DRG base rate — not one flat rate for every hospital. Pick this hospital's group (OHCA will have told you which one, or your billing office will know) to set the base rate directly, without needing the platform admin to enter it.

What do "Big / Urban / Teaching / Critical Access / Sole Community" mean?

Straight from OHCA's own 2006 DRG design report — each is a yes/no attribute from the hospital's CMS cost report (Form 2552):

Big ("Large Hospital") — more than 200 licensed beds (Worksheet S3-1, Line 1).
Urban — the hospital's urban (vs. rural) designation (Worksheet S2, Line 21).
Teaching — has an approved graduate medical education (intern/resident) program (Worksheet S2, Line 25 or 30.04).
Sole Community — CMS Sole Community Hospital designation (Worksheet S2, Line 26).
Critical Access — CMS-certified Critical Access Hospital (Worksheet S2, Line 30).

A group isn't one clean rule like "Critical Access = Group 3" — OHCA scored all 32 combinations of these 5 attributes by predicted cost and split them into 5 roughly-equal bands, so which group a given combination lands in depends on that ranking, not a single attribute. See docs/OK-MEDICAID-DRG.md.

Peer group

Cost-to-charge ratio (CCR)

Effective date

Texas Medicaid — Inpatient Settings

Grouped by APR-DRG (Grouper 40), not MS-DRG. Day/cost outlier add-ons apply only to clients age 20 and younger. Clients 21 and older have no outlier here — HHSC instead applies a $200,000-per-client-per-benefit-year cap tracked across all of that client's claims, which this tool can't enforce on a single encounter without storing patient identifiers (see docs/TX-MEDICAID-DRG.md).

Service Date

Patient Age

Payment won't exceed billed charges

Standard Dollar Amount (SDA)$0

DRG Lookup

DRG Code

Search by description

LOS (days)

Severity Range Estimate

Claim Lines

DRG	Description	Weight	LOS	Died	Charge ($)	DRG Pay	Outlier	Total

No claim lines yet

Enter a DRG code or search by description, set the length of stay, and Add Line.

Payment Summary View calculation detail →

Base Rate

DRG Payment

Outlier Add-On

Patient Copay (−)

Grand Total

DRG	Description	Weight	LOS	Base Pay	Outlier	Line Total

Patient Responsibility Estimate

Facility charge only — physicians and other professionals involved in the stay (surgeon, anesthesiologist, radiologist, pathologist, hospitalist, etc.) bill separately and are not included here. The printed estimate repeats this note.

Primary plan (BCBS OK)

Oklahoma Medicaid doesn't use a deductible/coinsurance plan design — the patient owes only the statutory inpatient copay ($10/day for the first 7 days, $5 on day 8, capped at $75/stay), already netted out of the facility payment above. The deductible/coinsurance/secondary fields below don't apply to a Medicaid claim and are hidden while this payer is selected.

Deductible Remaining ($)

Coinsurance % — patient share after deductible

Copay (flat $)

OOP Max Remaining ($)

Secondary coverage (estimate)

For a Medigap, supplemental, or employer gap plan that pays a share of the patient's leftover balance. A projection — not from a loaded contract. The hospital files the secondary claim; the actual amount is set then.

Secondary covers % of the remaining patient balance

Total Allowed

Deductible

Coinsurance

Copay

Primary (BCBS) Pays

Secondary Pays (est.)

Patient Owes