CMSPricer
CMSPricer is a Texas-based SaaS platform that reprices and edits Medicare claims at 100% of CMS rates. It serves payers, TPAs, PPOs, BPOs, self-funded employers, and auditing firms via a self-service pre-pay model with REST API and batch processing capabilities.
- Company typePrivate
- Founded2018
- HeadquartersDallas, United States
- Headcount101–250
- GTM typeB2B
- OfferingSoftware
What CMSPricer does
CMSPricer is a Texas-based SaaS platform that reprices and edits Medicare claims at 100% of CMS rates, serving payers, TPAs, PPOs, BPOs, self-funded employers, and healthcare auditing firms. Founded in 2018 and operated as a brand under Micro-Dyn (Micro-Dyn Medical), the company offers a web-based solution with no software installation required, supporting hand-key entry, batch/EDI uploads, and REST API integration for automated workflows into existing billing systems. The platform addresses the persistent 3-month data lag in CMS.gov by running frequent engine updates with the latest CMS policies and rates.
The platform is organized into five integrated modules: (1) the core CMSPricer engine covering all PPS types (IPPS, OPPS, ASC, IRF, SNF, DME, hospice, clinical labs, and physician claims via RBRVS); (2) the Contract Manager module for automated contract configuration and fee schedule management across FFS or PPO networks; (3) the Batch/API module for high-volume processing and system integration; (4) the Editing Only module for pre-submission claim validation running comprehensive CMS edits (LCD/NCD, NCCI, MUE, modifier, age, IOCE, CPT/RVU); and (5) the CMS.GOV PCPRICER module for complex Medicare CPT reimbursement calculations. The platform is HIPAA-compliant, does not store PHI, and uses EV SSL/SHA2/2048-bit encryption. Disclosed customer outcomes include 98% first-pass acceptance rates, 99% pricing accuracy under Contract Manager, 70-80% faster processing than manual repricing, and a 24-day reduction in accounts receivable days.
CMSPricer operates on a pre-pay, consumption-based revenue model with volume discounts, no contracts, and no sales team — a pure self-service, product-led growth motion. New users receive 5 free trial claims with no commitment. Customer acquisition is driven primarily by content marketing through 41+ blog pages, SEO, and a YouTube demo video. The company is self-funded with no disclosed venture capital, no publicly disclosed revenue, headcount, or employee data, and operates exclusively in the USA.
CMSPricer firmographics
Firmographics- Name
- CMSPricer
- Legal name
- CMS Pricer
- Website
- https://cmspricer.com
- Company type
- Private
- Founded year
- 2018
- Operating status
- Operating
- Headcount range
- 101–250 employees
- Short description
- CMSPricer is a Texas-based SaaS platform that reprices and edits Medicare claims at 100% of CMS rates. It serves payers, TPAs, PPOs, BPOs, self-funded employers, and auditing firms via a self-service pre-pay model with REST API and batch processing capabilities.
- Ownership category
- akta.pro rank
CMSPricer industry classification
Industry- Product category
- Healthcare Claims Management Software
- NAICS
- Software Publishers (513210)
- SIC
- Services-Prepackaged Software (7372), Services-Computer Programming, Data Processing, Etc. (7370)
- akta.pro primary industry
- Medicare Quality, Risk Adjustment & Stars Analytics/Services (FSAIAGAJ)
Keywords
Where CMSPricer is headquartered
LocationHeadquarters
- HQ city
- Dallas
- HQ country
- United States
- HQ region
- North America
Offices1 record
Markets served
CMSPricer business model
Business model- GTM type
- B2B
- Offering type
- Software
- Cost components
- Technology or R&D, Personnel, Operations, Marketing or Sales, Infrastructure
Revenue model
- Pre-pay SaaS Access: The company operates on a pre-pay model with volume discounting. Users purchase claims processing capacity in advance with no long-term contracts required. Pricing scales based on volume, rewarding higher usage with discounted rates.
- Free Trial: New users receive 5 claims free with no commitments, allowing them to evaluate the platform before purchasing.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Usage-based | Pay-as-you-go | Pre-pay consumption model with volume-based discounts |
Go-to-market motion2 records
Distribution channels2 records
Marketing channels4 records
CMSPricer product offering
Product offeringCore offering
CMSPricer provides a cloud-based SaaS platform that prices Medicare, Medicaid, and commercial claims at 100% of Medicare rates in seconds and validates claims with CMS-aligned edits before submission. It also offers a Contract Manager module to automate contract/fee-schedule pricing for FFS and PPO networks, with access via web UI, batch/EDI uploads, or REST API for payers, TPAs, BPOs, PPOs, self-funded employers, and auditing firms.
Product overview
CMSPricer is a unified SaaS-based Medicare claims repricing platform consisting of five integrated modules: the core CMSPricer platform for Medicare pricing at 100% of Medicare rates, the Contract Manager module for automated contract configuration and fee schedule management, the Batch/API module for high-volume processing and system integration, the Editing Only module for pre-submission claim validation with comprehensive CMS rule enforcement, and the CMS.GOV PCPRICER module for reimbursement calculations. The platform serves payers, PPOs, TPAs, BPOs, self-funded employers, and auditing firms, offering no-contract pre-pay pricing with web-based access available 24/7/365.
Differentiator
Problem solved
Functional benefit
Brands
- Contract Manager: A fully integrated contract configuration tool that automates claims pricing based on predetermined fee-for-service schedules, supporting multiple fee schedules across FFS or PPO networks.
Products and services
- CMSPricer Core Platform Web-based Medicare claims repricing SaaS platform that returns results in seconds priced at 100% of Medicare rates, supporting hand key entry, auto batch/EDI uploads, and imports/exports. Covers all PPS types of institutional and professional claims including IPPS, OPPS, ASC, IRF, SNF, DME, hospice, clinical labs, and physician/professional claims via RBRVS.
- Contract Manager Fully integrated contract configuration module that lets users set claims at specific rates and automate pricing based on predetermined fee-for-service schedules. Supports multiple fee schedules across FFS or PPO networks with dynamic rate adjustments and rule-based pricing by provider, facility, service type, and date range.
- Batch/API Solution High-volume claims processing solution enabling import of claims via CSV files, auto batch/EDI uploads, review/edit, and accurate Medicare PPS pricing. REST API using JSON supports automated workflows for TPAs, PPOs, BPOs, and self-funded employers.
- Editing Only Automated claim-editing solution that validates claims before submission. Runs comprehensive edits including diagnosis code validation, LCD/NCD checks, Medically Unlikely Edits (MUE), NCCI edits, modifier edits, age edits, Outpatient Code Edits (IOCE), and CPT/RVU edits for both Professional (CMS 1500) and Institutional (UB04) claim types.
- CMS.GOV PCPRICER Module that leverages CMS.gov PC Pricer logic for Medicare CPT code reimbursement calculations, handling complex pricing methodologies including anesthesia calculations, drug pricing, rural health clinic adjustments, and locality-based adjustments.
Quantifiable outcome
- 98% first-pass claim acceptance rate
- +5 more outcomes
Companies that use CMSPricer
Customer profileNamed customers1 record
Segments6 records
Ideal customer profiles4 records
CMSPricer technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- Yes
- API docs
- API detail
Core technology
AI maturity
App detail
Feature5 records
CMSPricer partnerships and signals
Strategic signalScale indicators8 records
Recent moves6 records
Expansion highlights4 records
CMSPricer competitors and assessment
Company assessmentBroad incumbents
- Cotiviti: Cotiviti provides payment accuracy, claims editing, and risk adjustment analytics for payers — overlapping with CMSPricer's editing and Medicare Advantage accuracy positioning, but at much larger enterprise scale.
- Experian Health: Experian Health provides identity, eligibility, claims management, and reimbursement solutions — overlapping with CMSPricer's claims pricing and editing capabilities as part of a broader healthcare data platform.
- Health Catalyst: Health Catalyst is a healthcare analytics and outcomes platform that touches payer-provider analytics and value-based care workflows — adjacent to CMSPricer's CMS accuracy and pricing analytics positioning.
- Availity: Availity operates a major healthcare clearinghouse and provider-payer collaboration platform with claims editing and pricing workflows — adjacent and partially overlapping with CMSPricer's claims editing and pricing engine.
- Change Healthcare (Optum): Change Healthcare, now part of Optum, provides claims processing, editing, and reimbursement services across the healthcare ecosystem — a broad incumbent with overlapping claims editing and pricing capabilities to CMSPricer.
- Waystar: Waystar is a broad healthcare revenue cycle management platform that includes claims processing, editing, and reimbursement — competing with CMSPricer's core pricing/editing modules as part of a much larger RCM suite.
Direct peers
- MultiPlan: MultiPlan operates a PPO network and provides healthcare cost management including repricing and claim cost containment — a direct comparable to CMSPricer's Contract Manager and PPO network pricing functionality.
- Lyric (formerly ClaimsXten): Lyric's ClaimsXten is one of the most widely deployed claims editing engines in the US, directly comparable to CMSPricer's Editing Only module for NCCI, MUE, LCD/NCD, and modifier validation.
- Zelis Healthcare: Zelis is a healthcare cost containment and claims pricing platform that offers repricing, network solutions, and claims editing — directly overlapping CMSPricer's Medicare repricing and Contract Manager capabilities for payers, TPAs, and self-funded employers.
Emerging players
- Innovaccer: Innovaccer offers a healthcare data platform with payer-provider connectivity, risk adjustment, and quality analytics — an emerging player that intersects CMSPricer's Medicare accuracy and risk/analytics positioning.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat5 records
Key risks6 records
Key highlights6 records
Customer concentration
CMSPricer social profiles
Digital presenceCMSPricer compliance and trust
Trust signalCompliance3 records
CMSPricer financial estimates
Financial estimateRevenue estimate
Valuation estimate
CMSPricer leadership team
Management profileNumber of profiles
CMSPricer funding detail
Funding detailFunding overview
Funding rounds
Investors
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
CMSPricer M&A and investment
M&A and investmentM&A
Investments
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about CMSPricer
What does CMSPricer do?
CMSPricer provides a cloud-based SaaS platform that prices Medicare, Medicaid, and commercial claims at 100% of Medicare rates in seconds and validates claims with CMS-aligned edits before submission. It also offers a Contract Manager module to automate contract/fee-schedule pricing for FFS and PPO networks, with access via web UI, batch/EDI uploads, or REST API for payers, TPAs, BPOs, PPOs, self-funded employers, and auditing firms.
Is CMSPricer a public or private company?
CMSPricer is a private company. It is classified as founder individual operated bootstrapped and is currently operating.
When was CMSPricer founded?
CMSPricer was founded in 2018. It employs 101 to 250 people.
Where is CMSPricer based?
CMSPricer is headquartered in Dallas, United States, in the North America region.
How does CMSPricer make money?
Two revenue lines are on record. Pre-pay SaaS Access are the primary driver. The others are free Trial.
Who are CMSPricer's main competitors?
Broad incumbents on record are Cotiviti, Experian Health, Health Catalyst, Availity, Change Healthcare (Optum) and Waystar. Direct peers are MultiPlan, Lyric (formerly ClaimsXten) and Zelis Healthcare. Innovaccer is listed as an emerging player.
Does CMSPricer have an API?
Yes. CMSPricer offers a REST API using JSON format that allows applications to submit pricing requests and receive results directly within existing systems. The API supports automated claims processing, real-time pricing, and seamless integration with EHR/EMR systems and clearinghouses. Organizations can configure which edits to enable, and CMS rule updates are automatically implemented through the API. Manual entry options include hand-key individual claims or auto batch/EDI uploads. Developer documentation is at cmspricer.com/our-solutions.
What industry is CMSPricer in?
CMSPricer's product category is Healthcare Claims Management Software. Its primary akta.pro industry code is FSAIAGAJ, Medicare Quality, Risk Adjustment & Stars Analytics/Services. Its NAICS code is 513210 and its SIC code is 7372.