Contracted Rates: How to Find Yours by CPT Code

Ask a practice manager what Aetna pays for a 99214 and you will usually get one of three answers: a number from memory, a number from the last remittance advice, or an honest "let me find out." The third answer is the correct one, and finding out is harder than it should be.

There are exactly three places your negotiated rate for a CPT code exists. Each is obtainable. Each has a specific weakness. And the practices that get paid correctly are the ones that hold all three next to each other.

The short version

The rest of this piece is how to get each one, and what a disagreement between them actually means.

Why your own contract usually can’t answer the question

Practices are often surprised that the document in the filing cabinet does not contain the number. Several reasons, all common:

The fee schedule is an exhibit, and the exhibit is incorporated by reference. The signature pages say the parties agree to the compensation set out in Exhibit B. Exhibit B was a spreadsheet emailed during negotiation, or a link to a provider portal, and it is not stapled to what you kept.

The rate is a formula, not a figure. "115% of the then-current Medicare Physician Fee Schedule for the locality in which services are rendered" is a rate, but it is not a number until you resolve three variables: which year's conversion factor, which geographic locality, and which RVU set. For 2026 the conversion factor is $33.5675 for clinicians in a qualifying alternative payment model and $33.4009 for everyone else — increases of 3.77% and 3.26% over 2025, effective January 1, 2026. If your contract is written as a percentage of Medicare, your rates changed on that date whether or not anyone told you.

The 2026 rule did something more structural, too. CMS reduced the share of indirect practice expense allocated to services performed in facility settings, on the reasoning that facilities now bear those costs, and finalised higher indirect practice expense values for office-based settings. So office-based and facility-based codes did not move by the same amount. A single blended assumption about "the Medicare increase" will be wrong for at least one half of your code mix.

"Then-current" and "prevailing" language means the payer can move it. A contract that pays the payer's "then-current fee schedule" has, in effect, delegated the number to the payer.

Amendments arrive as notices, not as contracts. Most commercial agreements renew evergreen and permit amendment on written notice. The document that changed your rate last year probably looked like a letter, and it is probably not filed with the contract.

One contract can carry several fee schedules. Carriers contract at the entity level and pay at the product and network level. One agreement, four networks, four schedules.

Your rights to be told the number vary by state, and it is worth knowing yours. Minnesota is unusually explicit: Minn. Stat. § 62Q.735 requires a health plan company to make available to the provider the fee schedule — or a method or process that lets the provider determine the fee schedule — for each service under the contract, and requires that any amendment altering the fee schedule be disclosed at least 45 days before it takes effect, with the provider free to terminate before it does. Texas requires HMOs to give contracting physicians and providers copies of applicable claim-processing policies and procedures, which is related but narrower. Many states have neither. Check your own insurance code before you assume the payer is obliged to answer.

Method 1 — Ask the payer, in a way that gets an answer

This works more often than practices expect, and it fails in predictable ways when the request is vague.

Send it in writing, to your provider relations or network management representative, and be specific about five things:

1. The entity. Your legal name, TIN, and the group NPI the contract is under — plus individual NPIs if the schedule varies by clinician.
2. The product and network. Not "Aetna" but the named network your patients are enrolled in. If you do not know, ask which networks your contract participates in; that answer is useful on its own.
3. The effective date. Ask for the currently effective schedule and the date it took effect. A schedule without an effective date is unusable in a dispute.
4. A code list. Do not ask for "the fee schedule" — that request routinely comes back as a percentage factor or not at all. Attach your codes. In most practices a couple of dozen CPT codes carry the large majority of commercial revenue; pull your top 25 to 30 by charge volume and ask about those.
5. The basis. If the rate is a percentage of Medicare, ask which year and which locality, in writing.

If your state has a disclosure statute, cite it. If your contract has a disclosure provision, quote the section number. Expect weeks rather than days, expect a partial answer, and expect to ask twice.

What you are really buying with this exercise is the effective date and the network name. Those two facts turn every other source of truth from a rumour into a comparison.

Method 2 — Back into it from your remittance advice

Your 835s know a great deal. The allowed amount is the figure the payer priced the claim at, and the write-down from your billed charge to that allowed amount appears as adjustment reason code CO-45 — "charge exceeds fee schedule / maximum allowable or contracted / legislated fee arrangement."

CO-45 is worth understanding precisely, because it appears on almost every commercial claim and is often misread. It is not a denial. It is a pricing adjustment: the contractual difference between what you charged and what your contract allows, and it is not billable to the patient. Staff who treat every CO-45 as something to appeal will waste their week. Staff who treat every CO-45 as correct will miss the ones that aren't.

The traps in reading allowed amounts as contract rates:

• If you billed below the allowed amount, the payer pays your charge. The remit then shows your own fee schedule, not the payer's. This is the single most expensive blind spot in the list, because it is invisible: nothing on the remit says "you could have been paid more." If any of your charges sit below any payer's allowed amount, you are funding the difference and cannot see it.
• Never use the paid amount. Paid is net of deductible, coinsurance and copay. In a high-deductible market, comparing paid to a contract rate manufactures underpayments that do not exist. Compare allowed to allowed.
• Edits move the number. Bundling and NCCI edits, multiple-procedure reduction, modifier pricing and assistant-surgeon percentages all produce an allowed amount that is correct and yet is not the base rate for that code.
• Place of service matters. Facility and non-facility pricing differ, and a code billed at POS 11 is not directly comparable to the same code at POS 22.
• Somebody else may have priced it. Repriced claims, secondary and coordination-of-benefits claims, and rented network access — sometimes called a silent PPO — can produce an allowed amount from a network you never signed.

Remits are excellent evidence of what happened. They are weak evidence of what was agreed.

Method 3 — The file your payer is required to publish

This is the source most practices do not know exists, and it is the only one that is both current and independent of your own filing.

The Transparency in Coverage final rules — issued November 12, 2020 by the Departments of the Treasury, Labor and HHS, at 85 FR 72158 — require non-grandfathered group health plans and issuers in the individual and group markets to publish machine-readable files disclosing their in-network negotiated rates and their out-of-network allowed amounts. The in-network file requirement applies to plan or policy years beginning on or after July 1, 2022, and the files must be updated monthly.

The in-network file lists, for a billing code, the rates the plan negotiated — attached to provider identifiers. The fields that decide whether a number means anything are these, and the allowed values come straight from CMS's own technical implementation guide:

To find the files: go to the payer's public "Transparency in Coverage" or "machine-readable files" page, which leads to a table-of-contents JSON index. That index lists, per plan and per network, the URLs of the in-network rate files. No login, no licence, no data agreement.

And then you hit the reason this data is simultaneously public and unavailable.

We read these files for 66 payers, and the scale is the whole story. Each payer publishes compressed JSON split across many files, one set per network, and the rate you want is one line among millions. Aetna's September 2026 files carry a single rate for 99213 for more than two million provider groups; UnitedHealthcare's for more than 800,000; Cigna's for more than 370,000. Finding yours means reading the payer's table of contents, working out which files belong to which networks, resolving the provider references in each file to NPIs and tax IDs, and only then reading the rate.

None of that is a reason the data is useless. It is the reason a practice manager with a spreadsheet cannot use it, which is a different problem.

The consequence shows up in the trade data. An MGMA Stat poll conducted December 30, 2025 found that just 18% of medical groups use Transparency in Coverage negotiated-rate data in payer contract negotiations. Forty-six per cent said they do not, and 36% did not know. The rates are published. Four in five groups are negotiating without them.

Reconciling the three

Do this for your top 25 codes by charge volume, once, and you will know more about your commercial revenue than most practices your size.

For each code, put four numbers in a row:

1. Your charge — what you bill.
2. Contract exhibit rate — if you have it, with its effective date.
3. Published rate — from the payer's current in-network file, for your NPI and TIN, billing_class: professional, negotiated_type of negotiated or fee schedule, in the network your patients are actually enrolled in.
4. Median allowed — from six months of remits for that code, unmodified, at your usual place of service.

Then read the disagreements. They are diagnostic:

What to do when the numbers disagree

Lead with the payer's own published figure, and cite it properly: the source file, its "as of" month, the network, and the negotiated_type. A contracting manager can dismiss a vendor's benchmark. It is considerably harder to dismiss the number their own employer published to satisfy a federal rule.

On a specific claim, appeal with four things: the claim identifier, the CARC on the remit, the allowed amount paid, and the published rate with its provenance. Ask for reprocessing, not for a conversation.

If the pattern is systemic rather than per-claim, it is a contracting conversation, not an appeals one — and that is the moment the same data becomes a negotiation exhibit rather than a complaint. Escalate provider relations → network management → your state department of insurance, in that order, and only after the contract's own dispute path is exhausted.

One caution: check the effective date before you call anything an underpayment. A rate that legitimately changed mid-year, under an amendment notice that somebody filed away, is not a payer error. It is a filing problem, and the fix is a calendar reminder rather than an appeal.

The honest summary

Your contract tells you what you agreed to, and is frequently incomplete. Your remits tell you what happened, and are shaped by edits and by your own charge master. The payer's published file tells you what the payer says it negotiated with you, is refreshed every month, and is the only one of the three you do not have to ask anyone's permission to read.

None of the three is sufficient. Together they are close to complete, and the work of putting them side by side is the work almost nobody is doing — which is precisely why it pays.

Which of those numbers to hold against which is its own question: allowed amount vs paid amount vs contracted rate walks through a remit line and shows the one comparison that finds an underpayment.

RateBench reads the Transparency in Coverage files for the payers we cover and builds your contracted rates into one fee schedule: your payers, by CPT code, with the network, the setting and a link to the source file behind every figure. Upload your allowed amounts and the underpayment check shows the codes allowed below the rate your payer published; rate monitoring emails you when one changes. A single rate lookup is free; the rest is on a paid plan from $99 a month.