HER Amendment 00002.pdf

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing items 8 and 15, and returning or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

E. IMPORTANT: Contractor is not is required to sign this document and return copies to the issuing office.

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE

2. AMENDMENT/MODIFICATION NUMBER 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQUISITION NUMBER 5. PROJECT NUMBER (If applicable)

7. ADMINISTERED BY (If other than Item 6) CODE

STANDARD FORM 30 (REV. 11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

FACILITY CODE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED (SEE ITEM 11)

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended. is not extended.

12. ACCOUNTING AND APPROPRIATION DATA (If required) copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NUMBER AS DESCRIBED IN ITEM 14.

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

NUMBER IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15C. DATE SIGNED

15A. NAME AND TITLE OF SIGNER (Type or print)

16C. DATE SIGNED

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

PAGE OF PAGES

6. ISSUED BY CODE

8. NAME AND ADDRESS OF CONTRACTOR (Number, street, county, State and ZIP Code) (X)

CODE

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

16B. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

Previous edition unusable

00002

Kathy Cole, Contract Specialist - FAO

Amendment No. 00002 is issued to incorporate changes to Attachment 2, Performance Work Statement identified on pages 2-5 of this amendment.

Any Technical Proposal revisions deemed necessary may be submitted by May 5, 2022 at 2:00 PM CST. If a revision is not submitted, the Government will assume your initial proposal is standing. At a minimum, a signed copy of this amendment must be returned by the deadline.

Federal Bureau of Prisons, Field Acquisition Office FCI Herlong 741-925 Herlong Access Road A25 Herlong, CA 96113 Kathy Cole/972-352-4523/k1cole@bop.gov

0062-21

15B61921R00000001

1 5

08/17/2021

Attachment 2 – Performance Work Statement

Within Attachment 2, Performance Work Statement, Output #3 on pages 5-8 of 10 is hereby removed in its entirety and replaced with the following:

Output #3: Submit properly-priced invoices for services rendered.

Overview. Upon completion of a treatment encounter, the Contractor shall prepare and submit proper invoices for services rendered under this contract. For the purpose of this contract, a specific definition for what documentation constitutes an invoice is provided below. A proper invoice shall include the information specified in FAR clause 52.212-4, Contract Terms and Conditions - Commercial Items, paragraph (g). Services shall be invoiced in accordance with the terms and conditions of the contract, including the payment rate structures specified in the contract.

Invoice/Medical Claims Adjudication. The institution will employ a process of invoice/medical claims adjudication to ensure, at a minimum, that the services billed by the contractor were properly authorized and ordered by the institution, are appropriately coded in compliance with Medicare coding policies (where applicable), are properly priced in accordance with the terms and conditions of the contract, and do not represent duplicate billings for payments already made. In addition, the institution may utilize the services of a third-party medical claims adjudicator to review medical claims submitted by the contractor under this contract. When requested by the institution, the contractor shall comply with all reasonable requests for additional invoice/medical claim/medical record documentation. All invoice payments shall be made by the institution and any disagreements regarding the paid amount of any invoice shall be resolved directly with the institution.

Invoice Definitions.

Line Items 1a - Inpatient Facility Services, 1b - Outpatient Facility Services, 2a – Inpatient Physician Services, and 2b – Outpatient Physician Services: At the outset of this contract, an invoice for services rendered under Line Items 1a, 1b, 2a, and 2b shall be a paper version of an invoice containing not more than 50 individual medical claims. Each invoice shall be supported with paper copies of Universal Billing (UB) 04 forms or Centers for Medicare and Medicaid Services (CMS) 1500 forms, as applicable, for each medical claim included in the invoice.

Following written notification to the Contractor by the Contracting Officer that a third-party medical claims adjudication service will be utilized by the institution, an invoice for services rendered under Line Items 1a, 1b, 2a, and 2b shall be a paper invoice detailing not more than 50 individual medical claims which have been electronically transmitted to the BOP's medical claims adjudicator via American National Standards Institute (ANSI) 837 format that also conforms to Medicare and Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic billing standards. For each medical claim included on the invoice, the contractor shall reference, at a minimum, the following information: Task Order number, inmate name, register number, date of service, provider of service name and NPI number, billed code, and contract amount billed. Medical claims detailed in the invoice shall be listed first in descending order by the Task Order number, second in alphabetic order by the inmate's last name, and third by ascending date of service (i.e., earliest to latest) when more than one medical claim is present for the same inmate within the same invoice. A copy of the invoice including the same fields listed above will also be provided to the institution in Microsoft Excel or comma-separated values (CSV) format. The electronic copy of the invoice shall be submitted to the institution using an encrypted email service.

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT-

CONTINUATION

CONTRACT ID CODE PAGE of

PAGES

If the Contractor’s proposal encompasses the provision of oral surgery and/or dental procedures, only those medical claims which represent adjunctive dental care will be submitted by the Contractor to the medical claims adjudication contractor for processing. Oral surgery and/or dental procedures which are not considered to be adjunctive dental care will be submitted to the institution for verification.

The Contractor shall not submit a medical claim for processing that the contractor knows or has reason to believe contains inaccurate, incomplete, or misleading information. Additionally, the Contractor shall only submit Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) provided by medical service providers. Medical claims which contain inaccurate, incomplete or misleading information shall be held by the Contractor and not submitted until such time as all lines are deemed to be accurate and complete. At that time, the Contractor may proceed with submitting the medical claim for processing and invoicing the institution for all services represented by that medical claim.

Line Items 2c1. Outpatient Institution Services-Optometrist, 2c2. Outpatient Institution Services- Mobile CT, and 2c3. Outpatient Institution Services-Mobile MRI: An invoice for services rendered under Line Items 2c1, 2c2, and 2c3 shall be be a paper invoice detailing the date(s) sessions were provided, the number of sessions provided, the unit pricing applied, and the extended total amount due. The BOP will not use the services of a third party medical claims adjudicator for verification of these services.

Provider Information.

Submission of Provider Data to the BOP's Medical Claims Adjudicator. Within 10 calendar days after notification that a third-party medical claims adjudication service will be utilized by the institution, the Contractor shall provide the BOP's medical claims adjudicator with a complete list of provider information, which will enable the medical claims adjudicator to accurately identify the correct payable amount for any provider performing services under the Contract. Specific informational requirements are provided in Attachment 10-A, List of Provider Information Requirements. Provider information supplied to the BOP's medical claims adjudicator should be appropriately marked to identify the data as proprietary information so that it may be adequately protected by the BOP and its contracted medical claims adjudicator. Provider information shall be submitted directly to the BOP's medical claims adjudicator. As individual providers are added to the contractor's network, the contractor shall provide the information listed on the List of Provider Information Requirements to the medical claims adjudicator no less than three business days prior to filing claims electronically for services rendered by such new providers.

National Provider Identifier (NPI) Numbers - The Contractor shall utilize only providers who have a current National Provider Identifier (NPI) number.

Technical Data for Submission of Medical Claims. Prior to the submission of an invoice to the institution, the Contractor shall electronically transmit the information found on each individual invoiced medical claim via ANSI 837 format only, to the BOP's medical claims adjudicator. Any claims submitted to the medical claims adjudicator’s claims clearinghouse with missing or invalid provider information will be automatically rejected in a 277CA Claims Acknowledgement message noting the missing or invalid provider information received.

After the Contractor's electronic transmission to the BOP's medical claims adjudicator, the Contractor shall promptly submit a paper copy of the invoice to the institution. The Contractor will also post the ANSI 837 file in an FTP site set up and maintained by the BOP's medical claims adjudicator. Address information for the submission of a paper claim to the BOP's medical claims adjudicator is provided in Attachment 10-B, Informational Requirements for Medical Claims, along with other pertinent details.

Procedures for Filing Corrected Medical Claims.

A corrected claim is a replacement of a previously submitted claim with claim line level denials or issues.

Previously submitted claims that were completely rejected or denied should be sent as a new claim rather than a corrected claim.

Facility Services: If it becomes necessary to file a corrected medical claim for facility services, the Contractor shall electronically transmit the information found on each individual corrected medical claim via ANSI 837i format only, to the BOP’s medical claims adjudicator. Institutional Provider corrected claims should include a value of '7' (Replacement of Prior Claim) in Loop 2300, Segment CLM05‐3.

Physician/Professional Services: If it becomes necessary to file a corrected medical claim for professional services, the Contractor shall electronically transmit the information found on each individual corrected medical claim via ANSI 837p format only, to the BOP’s medical claims adjudicator. Professional Service Provider corrected claims should include a value of '7' (Replacement of Prior Claim) in Loop 2300, Segment

CLM05‐3.

After the Contractor's submission to the BOP's medical claims adjudicator, the Contractor shall promptly submit a paper copy of the invoice or credit memo, as applicable, to the institution. Invoices for corrected medical claims shall be clearly marked as such and shall be separate from routine invoices. Invoices or credit memos for corrected medical claims shall detail information pertaining to the original medical claim submission (including any amount(s) previously paid and the associated invoice numbers) and shall bill only for the corrected medical claim submission or reflect the credit amount due for the corrected medical claim submission.

Payment by the Institution. The institution will pay all invoices directly to the Contractor. If the invoiced amount of a medical claim exceeds the adjudicated amount of that medical claim, the institution will take an administrative deduction from the invoice. The institution will provide written notification to the Contractor when an administrative deduction is taken from an invoice payment.

If the Contractor is in disagreement with the paid amount of a medical claim, the contractor will provide written notification to the institution of the disagreement along with the reasons why the Contractor believes the medical claim was paid incorrectly. The institution will interface between the Contractor and the medical claims adjudicator to bring resolution to any disagreements. If it is determined that a medical claim was paid incorrectly by the institution, interest on the underpayment will be paid when required by the Prompt Payment Act.

Timeliness of Medical Claims

Claims shall be submitted/invoiced within 90 calendar days after an inmate’s discharge or outpatient encounter or other service provided under this contract. Medical claims which are submitted/invoiced beyond the 90-day requirement shall constitute a performance deficiency under this output and shall be documented in the Contractor’s performance evaluations. Medical claims which are submitted/invoiced within the acceptable time period, but are found to contain errors or require further justification, will be rejected and shall be resubmitted/re-invoiced by the Contractor within 30 calendar days from the date of rejection. Upon resubmission, invoices for corrected medical claims shall bear the new date of submission.

No later than November 1 of each year, the Contractor shall stimulate the billing process by reviewing its records, including those of subcontracted providers, to determine an estimated amount of outstanding charges for services provided through 30 September of that year. Based upon information generated through this review process, the Contractor shall provide a written estimate to the institution of outstanding fiscal year obligations, supported by adequate documentation. This estimate and supporting documentation shall be provided to the Contracting Officer no later than 1 December of each year. The Contractor shall put forth its best efforts to ensure the accuracy of the annual estimate provided to the Government.

Prompt payment to health care providers. In accordance with FAR 12.213, the Contractor shall implement commercial practices for health care payers in the surrounding community for prompt payment of all health care providers performing services under this contract. Such prompt payment terms shall be a material part of all subcontracts/agreements awarded by the Contractor. The Contract shall ensure that all health care providers acknowledge the following notice upon award of a subcontract/agreement for performance under this contract.

Notice to Health Care Providers. All health care providers are hereby advised that the Bureau maintains no privity of contract with any party other than the prime contractor regarding performance of the above-referenced contract. Notwithstanding FAR 52.212-4(b), a subcontract or other agreement between the prime contractor and a health care provider is a private-party contract. As such, the Bureau will not intervene in disputes between prime contractor and any subcontractor/health care provider on any issue, including payment disputes. All subcontractors/health care providers are advised that payments due from the Bureau for performance under the prime contract will be paid only to the prime contractor. Accordingly, the prime contractor is responsible for remitting payments to subcontracts/health care providers in accordance with the terms of the negotiated subcontract/agreement, if any. By submitting a response to the solicitation and or by accepting this award the contractor acknowledges as such, the prime contractor and subcontractors/health care providers should look to the remedies afforded them under any such negotiated subcontract/agreement.

If the Contractor fails to make prompt payment to health care providers, the Contracting Officer will consider any “unjustified failure(s)” by the Contractor to make prompt payments to a health care provider when evaluating the Contractor’s performance. Any unjustified failures to make prompt payments to health care providers will be reported in the Contractor Performance Assessment Reporting System (CPARS). The Government may terminate this contract, or any part hereof, for cause in the event of any default by the prime contractor, of if the prime contractor fails to comply with any contract terms and conditions, or fails to provide the Government, upon request, with adequate assurances of future performance.

LIST OF PROVIDER INFORMATION REQUIREMENTS

ATTACHMENT 10-A

The Medical Claims Adjudication contractor will need the following data elements for each type of provider in your proposed network. Each provider record should be stored in the file as comma separated values (CSV) in a single row. A new row is created for each provider record.

Please note that there are three different file formats to submit depending on the type of provider(s) in your network:

1) For Institutional Providers

Field Number

Field Name Maximum Length

Notes Example

1 National Provider Identifier (NPI) Number

10 9876543210

2 Institution Name 70 XYZ Medical Center 3 Doing Business As

(DBA) Name 70 Leave blank if not applicable. XYZ Hospital Trust

4 EIN (Tax ID) Number 9 Enter as 9 digits with no dashes.

987654321

5 Mailing Address (Form W-9 Address)

55 Use the address found on the Form W-9.

PO Box 174256

6 Mailing City 40 Use the city found on the Form W-9.

Los Angeles

7 Mailing State 2 Use the state found on the Form W-9. Two-character abbreviation only.

CA

8 Mailing Zip Code 5 Use the zip code found on the Form W-9. Only 5 digits needed.

90001

9 Healthcare Provider Taxonomy Code

10 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

282N00000X

10 Healthcare Provider Taxonomy Name

70 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

General Acute Care Hospital

Sample CSV file record using the example data from above:

9876543210,XYZ Medical Center,XYZ Hospital Trust,987654321,PO Box 174256,Los Angeles,CA,90001,282N00000X,General Acute Care Hospital

2) For Individual Practitioners (Sole Providers)

Field Name Maximum Length

Notes Example

1 National Provider Identifier (NPI) Number

10 11223344550

2 Provider Last Name 35 Johnson 3 Provider First Name 20 Richard 4 Provider Middle Initial 1 L 5 Provider Suffix Text 7 Sr, DO 6 EIN (Tax ID) or SSN

Number 9 Enter as 9 digits with no dashes.

102030405

7 Physical Address 55 Address of the office or facility.

1111 Main Street

8 Physical City 40 City of the office or facility. Washington 9 Physical State 2 State of the office or facility.

Two-character abbreviation only.

DC

10 Physical Zip Code 5 Zip code of the office of facility. Only 5 digits needed.

20024

5 Mailing Address 55 If different than physical address.

P.O. Box 1718

6 Mailing City 40 If different than physical address.

Washington

7 Mailing State 2 If different than physical address.

DC

8 Mailing Zip Code 5 If different than physical address.

20001

9 Healthcare Provider Taxonomy Code

10 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

207RG0100X

10 Healthcare Provider Taxonomy Name

70 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

Gastroenterology Physician

1122334455,Johnson,Richard,L,”Sr, DO”,102030405,1111 Main Street,Washington,DC,20024,P.O.

Box,1718,Washington,DC,20001,207RG0100X,Gastroenterology Physician

3) Group Practices and Suppliers (please note, create a record for each rendering physician in the group who could treat BOP patients)

Field Name Maximum Length

Notes Example

1 Group National Provider Identifier (NPI) Number

10 99887766550

2 Group Name 35 ABC Orthopedic Trauma Surgery

3 Group Healthcare Provider Taxonomy Code

10 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

193400000X

4 Group Healthcare Provider Taxonomy Name

70 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

Single Specialty Group

5 Rendering Provider National Provider Identifier (NPI) Number

10 Be sure to create a record for each rendering physician in the group who may treat BOP patients.

55555222221

6 EIN (Tax ID) or SSN Number (group)

9 Enter as 9 digits with no dashes.

102030405

7 Rendering Provider Last Name

35 Smith

8 Rendering Provider First Name

20 Melanie

9 Rendering Provider Middle Initial

1 K

10 Rendering Provider Suffix Text

7 MD

11 Physical Address 55 Address of the office or facility.

1234 River Road

12 Physical City 40 City of the office or facility. Roseville 13 Physical State 2 State of the office or facility.

Two-character abbreviation only.

CA

14 Physical Zip Code 5 Zip code of the office of facility. Only 5 digits needed.

95747

15 Mailing Address 55 If different than physical address.

16 Mailing City 40 If different than physical

17 Mailing State 2 If different than physical

18 Mailing Zip Code 5 If different than physical

19 Rendering Provider Healthcare Provider Taxonomy Code

10 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

207XX0801X

20 Rendering Provider Healthcare Provider Taxonomy Name

70 Lookups of provider taxonomy codes can be performed on:

https://taxonomy.nucc.org/

Orthopedic Surgery Orthopedic Trauma

9988776655,ABC Orthopedic Trauma Surgery,193400000X,Single Specialty Group,55555222221,102030405,Smith,Melanie,K,MD,1234 River Road,Roseville,CA,95747,,,,,207XX0801X,Orthopedic Surgery Orthopedic Trauma

INFORMATIONAL REQUIREMENTS FOR MEDICAL CLAIMS

ATTACHMENT 10-B

1. Medical claims shall be transmitted in accordance with regulatory and industry standards for the submission of ANSI 837 transactions. The contractor shall be responsible for maintaining its information system(s) so that it remains compliant with such regulatory and industry standards.

Any system changes that are required by the BOP’s medical claims adjudicator that are not the result of a regulatory or industry-wide change shall be negotiated on a case-by-case basis.

2. Medical claims may be submitted electronically via the claims clearinghouse service of the contractor’s choosing to the payer code BOPMC which has been registered with the claims clearinghouse networks. As an alternative, the Medical Claims Adjudication contractor can also provide access to a web portal allowing uploading of ANSI 837 claim files or direct data entry of BOP claims if desired.

3. Each medical claim, whether submitted electronically or in hard copy, shall identify the inmate by his/her individual BOP inmate register number and shall reflect the patient’s relationship to insured as “self.” The inmate number shall be keyed with five digits, a hyphen, and three digits in the following format: 12345-678. In an electronically transmitted medical claim, this information shall be keyed at 2010BA NM109 for both facility and professional medical claims.

In a UB-04 institutional hardcopy medical claim, the BOP inmate register number shall be included in the Insured’s Unique ID field block 60. In a CMS-1500 professional hardcopy medical claim, the BOP inmate register number shall be included in the Insured’s I.D. Number field, block 1a.

4. Each medical claim, whether submitted electronically or in hard copy, shall identify the invoice number under which the individual medical claim is being invoiced. In an electronically transmitted medical claim, the invoice number shall be referenced in the Patient Account Number field submitted in the 2300 loop, CLM01 segment. In a UB-04 hardcopy medical claim submission, the invoice number shall be included in the Patient Control Number field, block 3a.

In a professional hardcopy medical claim submission, the invoice number shall be included in the Patient Account Number Field, block 26. The invoice number shall be limited to 13 characters.

Positions 1-3 will be the institution’s alpha facility code, positions 4-5 will be alpha/numeric and mutually agreed upon by the institution and contractor, and positions 6-13 will be alpha/numeric and sequential. Not all positions, 6-13, must be used. No special characters will be allowed.

5. The Institution’s 3-character alpha Facility Code will be transmitted in electronically submitted medical claims (either 837i or 837p format) in the Subscriber Group or Policy Number Field in the 2000B Loop, SBR03 segment. In a UB-04 institutional hard copy medical claim, the Institution Facility Code will be included in the Insurance Group No Field, block 62. In a CMS- 1500 professional hardcopy medical claim, the Institution Facility Code will be included in the Insured's Policy, Group, or FECA Number Field, block 11. An example of the Facility Codes in use at BOP facilities in Butner NC include:

• HER - Herlong FCI

INFORMATIONAL REQUIREMENTS FOR MEDICAL CLAIMS

ATTACHMENT 10-B

6. The Medical Claims Adjudication Contractor will perform automated validation of any NPI numbers received on a BOP claim at the EDI Gateway.

If a claim is received from a CMC with a NPI number that is not currently in their Provider Data

Submission, the claim will be automatically rejected at the EDI Gateway.

A CA277 Claims Acknowledgement message will be received with a Claim Status Code of “A7” and a Claim Status Category Code of “562” in the STC segments on the report explaining the rejection of the claim(s) due to missing or invalid NPI numbers.

The following fields on an 837i institutional claim or an 837p professional claim which could or must contain a valid NPI number within the Provider Data Submission will be checked:

I. 837i:

1. 2010AA NM109 Billing Entity Identification Code (required)

2. 2010AB NM109 Pay-To Provider Identification Number Code

3. 2310A NM109 Attending Provider Identification Code (required)

4. 2310B NM109 Operating Physician Identification Code

5. 2310C NM109 Other Operating Physician Identification Code

6. 2310E NM109 Service Facility Identification Code

7. 2420A NM109 Operating Physician Identification Code

8. 2420B NM109 Other Operating Physician Identification Code

ii. 837p:

1. 2010AA NM109 Billing Provider Identification Code (required)

2. 2310A NM109 Referring Physician Identification Code

3. 2310B NM109 Rendering Physician Identification Code (required)

4. 2310C NM109 Service Facility Location Identification Code (required)

5. 2310D NM109 Supervising Provider Name Identification Code

6. 2420A NM109 Rendering Provider Identification Code

7. 2420B NM109 Purchased Service Provider Identification Code Qualifier

7. Paper medical claims submitted to the medical claims adjudicator shall be mailed to the following address:

Mailing:

Apprio Inc.

c/o FBOP Medical Claims Adjudication Program 3191 Maguire Blvd. Suite 100 Orlando, FL 32803