# Payer Negotiated Rate Lookup (Transparency in Coverage) (`kevinserver24/payer-tic-negotiated-rate-lookup`) Actor

Looks up a health insurer's actual negotiated in-network rate for a plan and a CPT/HCPCS procedure code, read live -- stream-parsed, never fully downloaded -- from that payer's own federally mandated Transparency-in-Coverage machine-readable file (45 CFR 147.212).

- **URL**: https://apify.com/kevinserver24/payer-tic-negotiated-rate-lookup.md
- **Developed by:** [Kevin](https://apify.com/kevinserver24) (community)
- **Categories:** Other
- **Stats:** 2 total users, 1 monthly users, 0.0% runs succeeded, 0 bookmarks
- **User rating**: No ratings yet

## Pricing

$100.00 / 1,000 negotiated\_rate\_lookups

This Actor is paid per event. You are not charged for the Apify platform usage, but only a fixed price for specific events.

Learn more: https://docs.apify.com/actors/running/actors-in-store.md#pay-per-event

## What's an Apify Actor?

Actors are web data automations that power AI and operations. They run on the Apify platform to scrape websites, process data, connect APIs, and automate workflows.
In Batch mode, an Actor accepts a well-defined JSON input, performs an action which can take anything from a few seconds to a few hours,
and optionally produces a well-defined JSON output, datasets with results, or files in key-value store.
In Standby mode, an Actor provides a web server which can be used as a website, API, or an MCP server.
Actors are written with capital "A".

## How to integrate an Actor?

If asked about integration, you help developers integrate Actors into their projects.
You adapt to their stack and deliver integrations that are safe, well-documented, and production-ready.
The best way to integrate Actors is as follows.

- **AI agents and MCP clients** — the [Apify MCP server](https://docs.apify.com/integrations/mcp.md) at `https://mcp.apify.com` (remote, streamable HTTP, OAuth on first use).
- **Agentic workflows and local Actor development** — [Agent Skills](https://apify.com/.well-known/agent-skills/index.json) with the [Apify CLI](https://docs.apify.com/cli/docs.md): `npm install -g apify-cli`, then `apify login`.
- **JavaScript/TypeScript projects** — the official [JS/TS client](https://docs.apify.com/api/client/js/docs.md): `npm install apify-client`.
- **Python projects** — the official [Python client](https://docs.apify.com/api/client/python/docs.md): `pip install apify-client`.
- **Any other language** — the [REST API](https://docs.apify.com/api/v2.md).

For usage examples, see the [API](#api) section below.

For more details, see Apify documentation as [Markdown index](https://docs.apify.com/llms.txt) and [Markdown full-text](https://docs.apify.com/llms-full.txt).

# README

## Payer TiC Negotiated Rate Lookup

*An independent tool. It is not affiliated with, endorsed by, or operated by
any health insurer, payer, issuer or plan sponsor whose files it reads. All
data is read live from each payer's own federally mandated Transparency-in-
Coverage machine-readable file, never scraped from any member-facing site.*

Give it a payer's own table-of-contents URL, a plan (by name or plan ID),
and a CPT/HCPCS procedure code; get back the actual negotiated rate that
insurer pays in-network for that procedure under that plan -- the number
the No Surprises Act's Transparency in Coverage rule (45 CFR 147.212)
requires every US health plan and issuer to publish, and which almost
nobody can otherwise read.

### Why this is hard, and why that is the point

A payer's own machine-readable files are not small. Anthem's national
table-of-contents file alone measured 9.3 GB (gzip-compressed) on
2026-08-22; the in-network-rates files it links to are, per CMS's own
published guidance, "as large as one Terabyte" each. No ordinary tool
downloads that. This Actor never tries to: it stream-parses straight to the
one plan and one procedure code you asked for, discarding everything else
as it reads, so a lookup that would otherwise require downloading and
holding a file bigger than most laptops' RAM completes as a bounded scan
with a disclosed byte budget (`max_scan_mb`).

### What it returns

For each query: `payer_label` (read from the payer's own file, never from
your input), `plan_label`, the `procedure_code`/`code_type` you asked
about, `billing_class` (professional/institutional), `negotiated_rate`,
`negotiated_type`, an `in_network_provider_npi_count` (how many distinct
in-network providers this rate applies to -- never the providers'
identities), and `effective_date`. Every result also carries
`scan_complete`, so you can tell "this plan has no rate for this code" apart
from "the file is too large to have finished checking within the scan
budget you set" -- two very different findings.

### What it does not return, on purpose

No individual provider's NPI, name or TIN, and no raw file contents. An
NPI Type 1 record identifies a single practicing clinician -- a natural
person -- so only an aggregate count ever leaves this Actor, never the
identifiers themselves.

### Finding a payer's table-of-contents URL

Every payer publishes one on its own public Transparency-in-Coverage /
"machine-readable files" page (search "`<payer name>` transparency in
coverage machine readable files"). There is no central registry across
payers -- that absence is itself part of why this lookup is worth doing
instead of reading the number off a bill.

# Actor input Schema

## `queries` (type: `array`):

One lookup per entry. `toc_url` is the payer's own table-of-contents URL (find it on the payer's public Transparency-in-Coverage / machine-readable-files page -- every payer publishes its own, there is no central registry). `plan_query` matches a plan by exact plan\_id or by a case-insensitive substring of its plan\_name. `billing_code` is the CPT/HCPCS/etc. procedure code. Each query that resolves to at least one negotiated rate is billed once, however many rate rows it returns.

## `max_scan_mb` (type: `integer`):

How much of each (potentially gigabyte- or terabyte-sized) payer file to stream through looking for a match before giving up honestly. A plan or code that sits further into the file than this budget reaches is reported as 'not found within the scan budget' -- distinct from 'not found', and worth raising this number and trying again for. Larger values cost more run time.

## Actor input object example

```json
{
  "queries": [
    {
      "toc_url": "https://antm-pt-prod-dataz-nogbd-nophi-us-east1.s3.amazonaws.com/anthem/2026-08-01_anthem_index.json.gz",
      "plan_query": "PPO",
      "billing_code": "27447",
      "billing_code_type": "CPT"
    }
  ],
  "max_scan_mb": 300
}
```

# Actor output Schema

## `results` (type: `string`):

No description

# API

You can run this Actor programmatically using our API. Below are code examples in JavaScript, Python, and CLI, as well as the OpenAPI specification and MCP server setup.

## JavaScript example

```javascript
import { ApifyClient } from 'apify-client';

// Initialize the ApifyClient with your Apify API token
// Replace the '<YOUR_API_TOKEN>' with your token
const client = new ApifyClient({
    token: '<YOUR_API_TOKEN>',
});

// Prepare Actor input
const input = {
    "queries": [
        {
            "toc_url": "https://antm-pt-prod-dataz-nogbd-nophi-us-east1.s3.amazonaws.com/anthem/2026-08-01_anthem_index.json.gz",
            "plan_query": "PPO",
            "billing_code": "27447",
            "billing_code_type": "CPT"
        }
    ],
    "max_scan_mb": 300
};

// Run the Actor and wait for it to finish
const run = await client.actor("kevinserver24/payer-tic-negotiated-rate-lookup").call(input);

// Fetch and print Actor results from the run's dataset (if any)
console.log('Results from dataset');
console.log(`💾 Check your data here: https://console.apify.com/storage/datasets/${run.defaultDatasetId}`);
const { items } = await client.dataset(run.defaultDatasetId).listItems();
items.forEach((item) => {
    console.dir(item);
});

// 📚 Want to learn more 📖? Go to → https://docs.apify.com/api/client/js/docs

```

## Python example

```python
from apify_client import ApifyClient

# Initialize the ApifyClient with your Apify API token
# Replace '<YOUR_API_TOKEN>' with your token.
client = ApifyClient("<YOUR_API_TOKEN>")

# Prepare the Actor input
run_input = {
    "queries": [{
            "toc_url": "https://antm-pt-prod-dataz-nogbd-nophi-us-east1.s3.amazonaws.com/anthem/2026-08-01_anthem_index.json.gz",
            "plan_query": "PPO",
            "billing_code": "27447",
            "billing_code_type": "CPT",
        }],
    "max_scan_mb": 300,
}

# Run the Actor and wait for it to finish
run = client.actor("kevinserver24/payer-tic-negotiated-rate-lookup").call(run_input=run_input)

# Fetch and print Actor results from the run's dataset (if there are any)
print(f"💾 Check your data here: https://console.apify.com/storage/datasets/{run.default_dataset_id}")
for item in client.dataset(run.default_dataset_id).iterate_items():
    print(item)

# 📚 Want to learn more 📖? Go to → https://docs.apify.com/api/client/python/docs/quick-start

```

## CLI example

```bash
echo '{
  "queries": [
    {
      "toc_url": "https://antm-pt-prod-dataz-nogbd-nophi-us-east1.s3.amazonaws.com/anthem/2026-08-01_anthem_index.json.gz",
      "plan_query": "PPO",
      "billing_code": "27447",
      "billing_code_type": "CPT"
    }
  ],
  "max_scan_mb": 300
}' |
apify call kevinserver24/payer-tic-negotiated-rate-lookup --silent --output-dataset

```

## MCP server setup

```json
{
    "mcpServers": {
        "apify": {
            "type": "http",
            "url": "https://mcp.apify.com/?tools=fetch-actor-details,kevinserver24/payer-tic-negotiated-rate-lookup"
        }
    }
}

```

The hosted server signs you in with OAuth on first connect, so no API token belongs in this config. Clients without OAuth support can send an `Authorization: Bearer <APIFY_API_TOKEN>` header instead, using a token from API & Integrations in Apify Console (https://console.apify.com/settings/integrations).

## OpenAPI specification

Download the OpenAPI definition: https://api.apify.com/v2/actors/3RErmZIDgvaA9mB16/builds/V5JQieHJPqR5wxRwi/openapi.json