Attachment C CLAIM IMAGE 2JZN_Redacted.pdf
PDF 245 KB Posted
- Attached to
- High Claims Medical Bill Auditor
- Solicitation number
- S000000320
- Issued by
- Pulaski County, Little Rock City, Arkansas
About this file
This document appears to be an ANSI 837 medical claim submission related to a state and local contract opportunity for a High Claims Medical Bill Auditor in Arkansas. The contract involves the jurisdictions of Pulaski County and Little Rock City. The scope of work includes reviewing and auditing medical claims and billing data, with the goal of identifying and correcting overpayments or erroneous charges. The contract term and any renewal options are not specified. Pricing details are not provided, but the document shows various medical procedure codes, revenue codes, and associated costs totaling over $133,000. There are no details on any set-asides, incumbent vendors, funding sources, or other salient contractual information.
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Text version
0420 6 693.30 0430 6 825.40 0450 1 1383.50 0460 3 809.15 0470 3 1040.65 0610 1 2884.30 0922 18 2712.35
Claim Page: 2
TRANSACTION SET HEADER
HEAD Authorization Information Qualifier 00 HEAD Security Information Qualifier 01 HEAD Security Information ARK599 HEAD Interchange ID Qualifier ZZ HEAD Interchange Sender ID E2722 HEAD Interchange ID Qualifier ZZ HEAD Interchange Receiver ID 00520 HEAD Interchange Date 180710 HEAD Interchange Time 1400 HEAD Interchange Control Standards ID { HEAD Interchange Control Version Number 00501 HEAD Interchange Control Number 274246662 HEAD Acknowledgement Requested 0 HEAD Usage Indicator P HEAD Component Element Separator :
HEAD Functional Identifier Code HC HEAD Application Sender Code E2722 HEAD Application Receiver Code 00520 HEAD Date 20180710 HEAD Time 14005700 HEAD Group Control Number 1 HEAD Responsible Agency Code X HEAD Version Identifier Code 005010X223A2 HEAD Transaction Set Identifier Code 837 HEAD Transaction Set Control Number W!IR3AW0T HEAD Implementation Guide Version Name 005010X223A2 HEAD Hierarchical Structure Code 0019 HEAD Transaction Set Purpose Code 00 - 0 HEAD Originator Application Transaction ... 203801449 HEAD Transaction Set Creation Date 20180710 HEAD Transaction Set Creation Time 14005700 HEAD Claim or Encounter ID CH - Chargeable
SUBMITTER NAME INFORMATION
1000A Entity Identifier Code 41 - Submitter 1000A Entity Type Qualifier 2 - Non-Person Entity 1000A Submitter Last or Organization Name 1000A Identification Code Qualifier
1000A Submitter Identifier 1000A Contact Function Code IC 1000A Submitter Contact Name 1000A Communication Number Qualifier TE - Telephone 1000A Communication Number 1000A Communication Number Qualifier FX - Facsimile 1000A Communication Number
RECEIVER NAME INFORMATION
1000B Entity Identifier Code 40 - Receiver 1000B Entity Type Qualifier 2 - Non-Person Entity 1000B Receiver Name HEALTH ADVANTAGE 1000B Identification Code Qualifier 46 - Electronic Transmitter Identification Number
(ETIN)
1000B Receiver Primary Identifier 00520
BILLING PROVIDER HIERARCHICAL LEVEL
2000A Hierarchical ID Number 1 2000A Hierarchical Level Code 20 2000A Hierarchical Child Code 1 2000A Provider Code BI - Billing 2000A Reference Identification Qualifier PXC - Health Care Provider Taxonomy Code 2000A Provider Taxonomy Code
BILLING PROVIDER NAME INFORMATION
2010AA Entity Identifier Code 85 - Billing Provider 2010AA Entity Type Qualifier 2 - Non-Person Entity
ANSI Page: 1
2010AA Billing Provider Last or Organizati...
2010AA Identification Code Qualifier
2010AA Billing Provider Identifier 2010AA Billing Provider Address Line 2010AA Billing Provider City Name 2010AA Billing Provider State or Province ...
2010AA Billing Provider Postal Zone or ZIP...
2010AA Billing Provider Secondary Identifi... EI - Employer Identification Number 2010AA Billing Provider Additional Identif...
2010AA Contact Function Code IC 2010AA Billing Provider Contact Name PATIENT ACCOUNTS 2010AA Communication Number Qualifier TE 2010AA Communication Number
PAY-TO ADDRESS NAME INFORMATION
2010AB Pay-to Provider Address Line 2010AB Pay-to City Name 2010AB Pay-to State Code 2010AB Pay-to Postal Zone or ZIP Code
SUBSCRIBER INFORMATION
2000B Hierarchical ID Number 47 2000B Hierarchical Parent ID Number 1 2000B Hierarchical Level Code 22 2000B Hierarchical Child Code 0 2000B Payer Responsibility Sequence Numbe... P - Primary 2000B Individual Relationship Code 18 - Self 2000B Insured Group or Policy Number PSCLAS0100 2000B Claim Filing Indicator Code BL - Blue Cross Blue Shield
SUBSCRIBER NAME INFORMATION
2010BA Entity Identifier Code IL - Insured or Subscriber 2010BA Entity Type Qualifier 1 - Person 2010BA Subscriber Last Name 2010BA Subscriber First Name 2010BA Subscriber Middle Name 2010BA Identification Code Qualifier MI - Member Identification Number 2010BA Subscriber Primary Identifier 2010BA Subscriber Address Line 2010BA Subscriber City Name 2010BA Subscriber State Code 2010BA Subscriber Postal Zone or ZIP Code 2010BA Date Time Period Format Qualifier D8 2010BA Subscriber Birth Date 2010BA Subscriber Gender Code 2010BA Reference Identification Qualifier OP 2010BA Pay-To Plan Provider Additional Ide...
PAYER NAME INFORMATION
2010BB Entity Identifier Code PR - Payer 2010BB Entity Type Qualifier 2 - Non-Person Entity 2010BB Payer Name HEALTH ADVANTAGE 2010BB Identification Code Qualifier PI - Payor Identification 2010BB Payer Identifier BC01 2010BB Payer Address Line PO BOX 8069 2010BB Payer City Name LITTLE ROCK 2010BB Payer State Code AR 2010BB Payer Postal Zone or ZIP Code 722038069
CLAIM INFORMATION
2300 Patient Account Number 1157227400 2300 Total Claim Charge Amount 133680.69 2300 Facility Type Code 11 2300 Facility Code Qualifier A 2300 Claim Frequency Code 1 2300 Medicare Assignment Code A - Assigned
ANSI Page: 2
2300 Benefits Assignment Certification I... Y - Yes 2300 Release of Information Code Y - Yes, Provider has a Signed Statement
Permitting Release of Medical Billing Data Related to a Claim
2300 Date Time Qualifier 096 - 96 2300 Date Time Period Format Qualifier TM 2300 Statement Date 1608 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20180610-20180616 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 201806110105
2300 TYPE OF ADMISSION 1
2300 SOURCE OF ADMISSION 1
2300 PATIENT STATUS CODE 01
2300 Reference Identification Qualifier G1 - Prior Authorization Number 2300 Reference Identification Number 4574372-943329 2300 Reference Identification Qualifier D9 - Claim Number 2300 Reference Identification Number 2300 Reference Identification Qualifier EA - Medical Record Identification Number 2300 Reference Identification Number
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABK
2300 Industry Code S12100A
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABJ
2300 Industry Code S12100A
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABN
2300 Industry Code W208XXA
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABN
2300 Industry Code Y9317
2300 CODE LIST QUALIFIER CODE ABN
2300 Industry Code Y92828
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 471
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code J95821
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S0211DA
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code T797XXA
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S15102A
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code J9811
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S12100B
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S12091A
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S1194XA
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S060X0A
ANSI Page: 3
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code I10
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code M532X2
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S80212A
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code S80812A
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code M62838
2300 PRESENT ON ADMISSION INDICATOR N
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BBR
2300 Industry Code 0KC30ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20180611
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 0RG2071 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20180612
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 03HY32Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20180610
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 2W62X0Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20180610
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 06HM33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20180611
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 02HV33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20180611
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 11 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20180610
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 5.00
2300 AHIN CLAIM ID QUALIFIER CI
2300 AHIN CLAIM ID 0001UB9202CFF283
2300 ORIGINAL POLICY ID QUALIFIER OP
2300 ORIGINAL POLICY ID NUMBER PXGY0013102703
2300 INBOUND FILE VERSION QUALIFIER VE
2300 INBOUND FILE VERSION ID ANSI
2300 CROSS OVER INDICATOR NM - Normal Claim 2300 Original ICN Qualifier D9 2300 Original ICN 180710H02JZN
2300 ICN QUALIFIER - FROM PROVIDER D9
2300 BOB-ICN from provider/Dakota 180710H02JZN
ATTENDING PROVIDER NAME INFORMATION
2310A Entity Identifier Code 2310A Entity Type Qualifier 1 - Person
ANSI Page: 4
2310A Attending Provider Last Name 2310A Attending Provider First Name 2310A Attending Provider Middle Name 2310A Identification Code Qualifier XX - Centers for Medicare and Medicaid Services
National Provider Identifier 2310A Attending Provider Identifier
OPERATING PHYSICIAN INFORMATION
2310B Entity Identifier Code 2310B Entity Type Qualifier 1 - Person 2310B Operating Provider Last or Organiza...
2310B Operating Provider First Name 2310B Operating Provider Middle Name 2310B Identification Code Qualifier XX - Centers for Medicare and Medicaid Services
National Provider Identifier 2310B Operating Provider Identifier
SERVICE LINE NUMBER INFORMATION
2400 Assigned Number 1
2400 INSTITUTIONAL SERVICE LINE 2400 0001SV2 0001
2400 Service Line Revenue Code 0101 2400 Line Item Charge Amount 3870.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-1 2400 Assigned Number 2
2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001
2400 Service Line Revenue Code 0203 2400 Line Item Charge Amount 13080.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-2 2400 Assigned Number 3
2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001
2400 Service Line Revenue Code 0203 2400 Line Item Charge Amount 7480.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-3 2400 Assigned Number 4
2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001
2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 9120.78 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1498 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-4 2400 Assigned Number 5
2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001
2400 Service Line Revenue Code 0255 2400 Line Item Charge Amount 345.46 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1003 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-5 2400 Assigned Number 6
2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001
2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 5536.21 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 84 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-6 2400 Assigned Number 7
ANSI Page: 5
2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001
2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 2239.92 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 34 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-7 2400 Assigned Number 8
2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001
2400 Service Line Revenue Code 0273 2400 Line Item Charge Amount 4.50 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-8 2400 Assigned Number 9
2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001
2400 Service Line Revenue Code 0274 2400 Line Item Charge Amount 325.85 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-9 2400 Assigned Number 10
2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001
2400 Service Line Revenue Code 0278 2400 Line Item Charge Amount 26893.08 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 19 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-10 2400 Assigned Number 11
2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001
2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 1658.15 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 19 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-11 2400 Assigned Number 12
2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001
2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 7545.65 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 39 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-12 2400 Assigned Number 13
2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001
2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 1709.65 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 28 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-13 2400 Assigned Number 14
2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001
2400 Service Line Revenue Code 0306 2400 Line Item Charge Amount 1036.20 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-14 2400 Assigned Number 15
2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001
2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 1455.00
ANSI Page: 6
2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 4 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-15 2400 Assigned Number 16
2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001
2400 Service Line Revenue Code 0324 2400 Line Item Charge Amount 1405.50 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-16 2400 Assigned Number 17
2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001
2400 Service Line Revenue Code 0350 2400 Line Item Charge Amount 8644.20 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-17 2400 Assigned Number 18
2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001
2400 Service Line Revenue Code 0360 2400 Line Item Charge Amount 13427.10 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 17 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-18 2400 Assigned Number 19
2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001
2400 Service Line Revenue Code 0361 2400 Line Item Charge Amount 5585.10 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-19 2400 Assigned Number 20
2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001
2400 Service Line Revenue Code 0370 2400 Line Item Charge Amount 6598.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 38 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-20 2400 Assigned Number 21
2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001
2400 Service Line Revenue Code 0390 2400 Line Item Charge Amount 413.99 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-21 2400 Assigned Number 22
2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001
2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 4957.70 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 3 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-22 2400 Assigned Number 23
2400 INSTITUTIONAL SERVICE LINE 2400 0023SV2 0001
2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 693.30 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 6 2400 Line Item Control Number 6R - Provider Control Number
ANSI Page: 7
2400 Repriced Line Item Reference Number 1157227400-23 2400 Assigned Number 24
2400 INSTITUTIONAL SERVICE LINE 2400 0024SV2 0001
2400 Service Line Revenue Code 0430 2400 Line Item Charge Amount 825.40 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 6 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-24 2400 Assigned Number 25
2400 INSTITUTIONAL SERVICE LINE 2400 0025SV2 0001
2400 Service Line Revenue Code 0450 2400 Line Item Charge Amount 1383.50 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-25 2400 Assigned Number 26
2400 INSTITUTIONAL SERVICE LINE 2400 0026SV2 0001
2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 809.15 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 3 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-26 2400 Assigned Number 27
2400 INSTITUTIONAL SERVICE LINE 2400 0027SV2 0001
2400 Service Line Revenue Code 0470 2400 Line Item Charge Amount 1040.65 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 3 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-27 2400 Assigned Number 28
2400 INSTITUTIONAL SERVICE LINE 2400 0028SV2 0001
2400 Service Line Revenue Code 0610 2400 Line Item Charge Amount 2884.30 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-28 2400 Assigned Number 29
2400 INSTITUTIONAL SERVICE LINE 2400 0029SV2 0001
2400 Service Line Revenue Code 0922 2400 Line Item Charge Amount 2712.35 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 18 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1157227400-29
ANSI Page: 8
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