Attachment D CLAIM 2R72_Redacted.pdf
PDF 241 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 attachment related to a state and local contract opportunity for a High Claims Medical Bill Auditor in the state of Arkansas, specifically involving Pulaski County and the City of Little Rock. The attachment appears to be a medical billing claim that includes details on the patient, the services provided, the amounts billed, and the provider information. The contract opportunity requires an expert in reviewing and auditing high-value medical claims to ensure accurate billing and appropriate reimbursement. The contract term and other specific details of the opportunity are not provided in this attachment.
The attachment provides a detailed breakdown of the medical services, including revenue codes, line item charges, units of service, and other relevant billing information. This information would be critical for the auditor to review the claim and validate the accuracy of the billing. The auditor would need to have expertise in medical coding, billing practices, and reimbursement policies to effectively review and assess the legitimacy of the claims.
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Text version
0430 4 838.40 0460 5 1654.15 0470 4 903.80 0481 90 61665.15 0483 9 4851.30 0610 2 5824.25 0730 1 128.25 0740 2 7985.40 0920 10 619.50 0921 7 3600.10
Claim Page: 2
TRANSACTION SET HEADER
HEAD Authorization Information Qualifier 00 HEAD Security Information Qualifier 01 HEAD Security Information HEAD Interchange ID Qualifier ZZ HEAD Interchange Sender ID HEAD Interchange ID Qualifier ZZ HEAD Interchange Receiver ID 00520 HEAD Interchange Date 210319 HEAD Interchange Time 1730 HEAD Interchange Control Standards ID { HEAD Interchange Control Version Number 00501 HEAD Interchange Control Number HEAD Acknowledgement Requested 0 HEAD Usage Indicator P HEAD Component Element Separator :
HEAD Functional Identifier Code HC HEAD Application Sender Code HEAD Application Receiver Code 00520 HEAD Date 20210319 HEAD Time 17300000 HEAD Group Control Number 1 HEAD Responsible Agency Code X HEAD Version Identifier Code HEAD Transaction Set Identifier Code 837 HEAD Transaction Set Control Number HEAD Implementation Guide Version Name HEAD Hierarchical Structure Code 0019 HEAD Transaction Set Purpose Code 00 - 0 HEAD Originator Application Transaction ...
HEAD Transaction Set Creation Date 20210319 HEAD Transaction Set Creation Time 17300000 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 46 - Electronic Transmitter Identification Number
(ETIN)
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 1000A Communication Number Qualifier EM - Electronic Mail 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
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
ANSI Page: 1
2010AA Entity Identifier Code 85 - Billing Provider 2010AA Entity Type Qualifier 2 - Non-Person Entity 2010AA Billing Provider Last or Organizati...
2010AA Identification Code Qualifier XX - Centers for Medicare and Medicaid Services
National Provider Identifier 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 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 62 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 ARKANSAS BCBS 2010BB Identification Code Qualifier PI - Payor Identification 2010BB Payer Identifier 00520 2010BB Payer Address Line 2010BB Payer City Name 2010BB Payer State Code 2010BB Payer Postal Zone or ZIP Code
CLAIM INFORMATION
2300 Patient Account Number 1246767508 2300 Total Claim Charge Amount 251480.70 2300 Facility Type Code 11 2300 Facility Code Qualifier A
ANSI Page: 2
2300 Claim Frequency Code 7 2300 Medicare Assignment Code A - Assigned 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 1528 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20190501-20190516 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 201905011229
2300 TYPE OF ADMISSION 1
2300 SOURCE OF ADMISSION 4
2300 PATIENT STATUS CODE 01
2300 Reference Identification Qualifier G1 - Prior Authorization Number 2300 Reference Identification Number 2300 Reference Identification Qualifier F8 - Original Reference Number 2300 Reference Identification Number 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 Note Reference Code ADD - Additional Information 2300 Claim Note Text CORRECTED CLAIM
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABK
2300 Industry Code P285
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABJ
2300 Industry Code P285
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 793
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P610
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P369
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code G936
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P90
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Q228
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P9160
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Q211
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P612
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code I313
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P8330
2300 PRESENT ON ADMISSION INDICATOR N
ANSI Page: 3
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P284
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P929
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P7422
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code I959
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P7421
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P2912
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P84
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BBR
2300 Industry Code 5A1522G 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20190501
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 03QH0ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20190505
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 02HV33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20190506
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BI - Occurrence Span 2300 Industry Code 71 2300 Date Time Period Format Qualifier RD8 2300 Date Time Period 20190429-20190501
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 20190429
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 15.00
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BG - Condition 2300 Industry Code D1
2300 AHIN CLAIM ID QUALIFIER CI
2300 AHIN CLAIM ID 0001UB9203359C50
2300 ORIGINAL POLICY ID QUALIFIER OP
2300 ORIGINAL POLICY ID NUMBER PXGY0091070302
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 210322H029IK
2300 ICN QUALIFIER - FROM PROVIDER D9
2300 BOB-ICN from provider/Dakota 190603H12R72
ATTENDING PROVIDER NAME INFORMATION
2310A Entity Identifier Code
ANSI Page: 4
2310A Entity Type Qualifier 1 - Person 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 Operating Provider Name Suffix 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 0174 2400 Line Item Charge Amount 25875.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-3 2400 Assigned Number 2
2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 24620.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 4 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-4 2400 Assigned Number 3
2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 21375.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-2 2400 Assigned Number 4
2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 3325.00 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 1246767508-1 2400 Assigned Number 5
2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001
2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 15820.01 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1175 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-5 2400 Assigned Number 6
2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001
2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 1464.66 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 36 2400 Line Item Control Number 6R - Provider Control Number
ANSI Page: 5
2400 Repriced Line Item Reference Number 1246767508-6 2400 Assigned Number 7
2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001
2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 2704.67 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 33 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-7 2400 Assigned Number 8
2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001
2400 Service Line Revenue Code 0278 2400 Line Item Charge Amount 145.76 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 1246767508-8 2400 Assigned Number 9
2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001
2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 3498.74 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 58 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-9 2400 Assigned Number 10
2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001
2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 23689.20 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 127 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-10 2400 Assigned Number 11
2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001
2400 Service Line Revenue Code 0302 2400 Line Item Charge Amount 211.65 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 1246767508-11 2400 Assigned Number 12
2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001
2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 8377.25 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 127 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-12 2400 Assigned Number 13
2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001
2400 Service Line Revenue Code 0306 2400 Line Item Charge Amount 1718.40 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 12 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-13 2400 Assigned Number 14
2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001
2400 Service Line Revenue Code 0307 2400 Line Item Charge Amount 170.40 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 1246767508-14 2400 Assigned Number 15
2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001
ANSI Page: 6
2400 Service Line Revenue Code 0310 2400 Line Item Charge Amount 13.26 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 1246767508-15 2400 Assigned Number 16
2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001
2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 1447.45 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 8 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-16 2400 Assigned Number 17
2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001
2400 Service Line Revenue Code 0324 2400 Line Item Charge Amount 2580.30 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-17 2400 Assigned Number 18
2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001
2400 Service Line Revenue Code 0360 2400 Line Item Charge Amount 5101.55 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 1246767508-18 2400 Assigned Number 19
2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001
2400 Service Line Revenue Code 0390 2400 Line Item Charge Amount 1451.45 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 461 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-19 2400 Assigned Number 20
2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001
2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 4741.80 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 7 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-20 2400 Assigned Number 21
2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001
2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 14707.45 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 7 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-21 2400 Assigned Number 22
2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001
2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 371.40 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 1246767508-22 2400 Assigned Number 23
2400 INSTITUTIONAL SERVICE LINE 2400 0023SV2 0001
2400 Service Line Revenue Code 0430 2400 Line Item Charge Amount 838.40 2400 BASIS FOR MEASUREMENT CODE UN - Unit
ANSI Page: 7
2400 Service Unit Count 4 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-23 2400 Assigned Number 24
2400 INSTITUTIONAL SERVICE LINE 2400 0024SV2 0001
2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 1654.15 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 1246767508-24 2400 Assigned Number 25
2400 INSTITUTIONAL SERVICE LINE 2400 0025SV2 0001
2400 Service Line Revenue Code 0470 2400 Line Item Charge Amount 903.80 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 1246767508-25 2400 Assigned Number 26
2400 INSTITUTIONAL SERVICE LINE 2400 0026SV2 0001
2400 Service Line Revenue Code 0481 2400 Line Item Charge Amount 61665.15 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 90 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-26 2400 Assigned Number 27
2400 INSTITUTIONAL SERVICE LINE 2400 0027SV2 0001
2400 Service Line Revenue Code 0483 2400 Line Item Charge Amount 4851.30 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-27 2400 Assigned Number 28
2400 INSTITUTIONAL SERVICE LINE 2400 0028SV2 0001
2400 Service Line Revenue Code 0610 2400 Line Item Charge Amount 5824.25 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 1246767508-28 2400 Assigned Number 29
2400 INSTITUTIONAL SERVICE LINE 2400 0029SV2 0001
2400 Service Line Revenue Code 0730 2400 Line Item Charge Amount 128.25 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 1246767508-29 2400 Assigned Number 30
2400 INSTITUTIONAL SERVICE LINE 2400 0030SV2 0001
2400 Service Line Revenue Code 0740 2400 Line Item Charge Amount 7985.40 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 1246767508-30 2400 Assigned Number 31
2400 INSTITUTIONAL SERVICE LINE 2400 0031SV2 0001
2400 Service Line Revenue Code 0920 2400 Line Item Charge Amount 619.50 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 10 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-31
ANSI Page: 8
2400 Assigned Number 32
2400 INSTITUTIONAL SERVICE LINE 2400 0032SV2 0001
2400 Service Line Revenue Code 0921 2400 Line Item Charge Amount 3600.10 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 7 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1246767508-32
ANSI Page: 9
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