The Medicare codes without a national rate now have local answers

Most Medicare Physician Fee Schedule lookups end with a formula: RVUs, geographic adjustments, and a conversion factor produce a payment amount. A status-C code ends differently. CMS publishes no national amount and assigns the price to the regional Medicare Administrative Contractor instead.

Until now, Localis handled that boundary honestly but not completely. A carrier-priced code returned no national amount and a reason instead of a fake $0.00. That answer prevented a bad calculation, but it still left the useful number scattered across contractor websites.

This release adds a local source layer: carrier-priced amounts from Noridian's JE and JF jurisdictions and First Coast's JN jurisdiction, attached to the exact locality and source file that published them. It also adds team code watchlists, release-impact analysis, and a public pricing-rule coverage matrix. The common thread is simple: a payment answer should show both what we know and where the answer stops.

Why a local source matters

Code 78815 makes the problem concrete. It has no national Physician Fee Schedule amount, even though Medicare providers bill it routinely. A national calculator cannot produce the right answer because the required number is published locally by the responsible contractor.

What JE, JF, and JN mean in practice

Noridian is a Medicare Administrative Contractor: a private company contracted by CMS to process Original Medicare fee-for-service claims, make payments, enroll providers, and administer other Medicare operations in an assigned region. Providers are generally assigned to the A/B MAC covering the state where they are located. CMS explains the MAC role and its geographic assignment rule.

JE and JF are Noridian's Part A/B geographic jurisdictions. JN is First Coast's:

CMS publishes the current JE facts and JF facts. CMS also publishes the current JN award and membership.

For this release, the practical scope is narrower than everything Noridian does. We ingest Noridian's Part B C-status professional fee schedules. We are not claiming coverage for Medicare Advantage, DME schedules, or every Original Medicare payment rule in those states.

A jurisdiction is also not a payment locality. JE tells us that Noridian is the responsible contractor for a California provider; it does not choose among California's many published locality amounts. State identifies the broad MAC jurisdiction. ZIP, resolved through CMS's crosswalk, identifies the publishing locality and therefore the applicable carrier-priced schedule.

What the first MAC release covers

The current dataset contains January 2026 carrier-priced schedules for all 43 Noridian JE/JF publishing localities and all five First Coast JN publishing localities: 30,017 fee rows covering 609 distinct codes. Each schedule stores:

• contractor and jurisdiction;
• the publisher's locality label;
• normalized CMS carrier and locality codes;
• effective date;
• participating, nonparticipating, and limiting-charge amounts;
• modifier and the publisher's raw note flag; and
• source URL, file identity, and retrieval time, so a corrected file is detected automatically.

The source identity matters because these figures do not come from the national RVU formula. For 78815, Noridian's January files publish a participating amount of $1,571.27 for Nevada Area 00 and $1,844.37 for California Area 18. Those are two contractor-published locality facts, not two variants of a national amount.

First Coast's 2026 schedules publish 78815 at $1,480.41 in Florida Area 99, $1,567.78 in Florida Area 03, $1,613.90 in Florida Area 04, and $1,577.83 in both Puerto Rico Area 20 and U.S. Virgin Islands Area 50. All 12 highest-spend carrier-priced codes are present in every JN bundle.

For mainland Florida, the same authoritative archive now extends through 2022, stored as the same immutable, source-linked schedules. Older Puerto Rico and U.S. Virgin Islands files are not backfilled because First Coast's archive links are inconsistent; their current 2026 coverage remains available.

Current status-C code pages now show the latest held schedule for each covered locality, including every modifier row, note, effective date, and direct source link. Historical PFS pages deliberately do not show today's MAC files; mixing a historical national release with a current contractor schedule would describe two different periods as if they were one.

When a contractor republishes the same locality and effective period, the old file is superseded rather than overwritten. The current answer moves forward, but the previous source file remains identifiable—the same immutability rule used for CMS's national releases.

Localis checks Noridian and First Coast's published coverage weekly for corrections. A changed source creates a new current version without erasing the schedule it replaced, and problems are flagged before they reach a customer.

ZIP now selects the actual MAC locality

A jurisdiction alone is not precise enough. JE includes California, Nevada, and Hawaii, and California alone contains many pricing localities. Returning every JE amount for a Nevada ZIP would narrow the search without answering it.

The authenticated endpoint accepts a ZIP and resolves it through CMS's versioned ZIP-to-carrier/locality crosswalk:

curl "https://localishealth.com/v1/mac-fees/78815?zip=89101" \
  -H "Authorization: Bearer sk_live_…"

The response echoes the resolution before returning the matching schedule:

{
  "selection": {
    "basis": "zip",
    "zip": "89101",
    "state": "NV",
    "jurisdiction": "JE",
    "mac_code": "01312",
    "locality_code": "00",
    "exact_locality": true,
    "ambiguous_locality": false
  }
}

The join uses the canonical carrier/locality pair, not a fuzzy comparison of names. That distinction handles cases such as Hawaii and Guam, which share a CMS publishing locality even though their state or territory abbreviations differ.

A state filter resolves only the A/B jurisdiction and returns all covered localities inside it. A zip filter can select the locality. If CMS flags a 5-digit ZIP as spanning more than one locality, the response says ambiguous_locality: true and uses only the crosswalk's dominant locality. Full disambiguation still needs the ZIP+4 override dataset; supplying false precision would be worse than carrying the limitation in the response.

MAC amounts remain separate from /v1/rates. A contractor-published locality amount is not silently blended into a national formula response just because a ZIP was supplied. Callers have to ask for the MAC dataset explicitly.

A release change now has a practice-specific answer

CMS release notes can say a conversion factor or RVU changed. A billing team usually needs a different answer: which of our codes moved, and what does that mean across our volume?

Team API tokens can now maintain one default watchlist with GET /v1/watchlist and PUT /v1/watchlist. Each line is a code, optional modifier, setting, and optional annual units:

{
  "lines": [
    { "code": "99213", "setting": "non_facility", "annual_units": 4200 },
    { "code": "78815", "setting": "facility", "annual_units": 120 }
  ]
}

This is aggregate practice reference data, not claim data: no patient, service date, account number, or remit enters the table.

GET /v1/watchlist/impact prices every watched line through the same rate engine used by the rest of the product. The default comparison is the selected release against the prior quarter. When annual units are present, the response also multiplies each per-unit change into an annualized dollar impact and sums the comparable lines.

The second baseline is for a particularly painful CMS event:

baseline=prior_revision

That compares the current release with the revision it superseded for the same quarter. It answers, "What did CMS retroactively correct for a period we may already have billed?" and marks the result retroactive: true.

Every watched line stays in the response. Unchanged codes are counted as unchanged. Carrier-priced codes or codes missing from one release remain as non-comparable rows with a reason. Silently dropping those lines would make a partial impact report look complete.

The new watchlist and impact functionality is available to team-token integrations.

The methodology now says what is not applied

A correct rate is partly a list of calculations and partly a list of rules that were not guessed. The new pricing-rule coverage matrix documents 25 rules across formula and payability, geography, caps, modifiers, multiple-procedure reductions, and claim edits. The same catalog is available as GET /v1/pricing-rules.

The matrix distinguishes three states:

• Applied: the PFS formula, status-driven payability, ZIP locality, anesthesia, OPPS caps, sequestration, standard MPPR, NCCI PTP, and MUE, among others.
• Partially applied: rules such as the professional/technical split and bilateral surgery where the supported cases and simplifications need to be named.
• Not applied: endoscopy, imaging, therapy, cardiovascular, and ophthalmology MPPR variants; multi-unit MPPR ranking; and global-period enforcement.

"Not applied" never means a guessed discount. The engine keeps the supported base amount and returns a reason explaining which adjustment was not modeled. Publishing that boundary makes an API response auditable before it becomes a variance report or contract decision.

What is covered—and what is not

This is bounded MAC coverage, not a nationwide carrier-priced product. Noridian JE/JF and First Coast JN are covered. Novitas JH/JL and the remaining contractors remain outside the dataset. A 404 from the MAC endpoint means "not on file in current coverage" and never supplies an implied zero.

You can inspect the 78815 locality amounts, read the API documentation, or review the full pricing-rule matrix. The national rate engine has not become more willing to guess. It now has a local dataset to consult where a national answer genuinely does not exist.