Attachment F CLAIM IMAGE _ 293O_Redacted.pdf

226 KB Posted

Attached to
High Claims Medical Bill Auditor
Solicitation number
S000000320
Issued by
Pulaski County, Little Rock City, Arkansas

About this file

Written by GovTribe AI ·

This document is a medical claim filed with Arkansas Blue Cross Blue Shield by St. Vincent Health, a health care provider located in Little Rock, Arkansas. The claim details a variety of medical procedures and services provided to a patient over multiple days, including diagnostic imaging, surgical procedures, and hospital room charges. The total claimed amount is $275,620.08.

The related state and local contract opportunity is for a High Claims Medical Bill Auditor to serve Pulaski County and the city of Little Rock, Arkansas. The scope of work likely involves reviewing and validating high-cost medical claims submitted to the respective jurisdictions, identifying potential overcharges or inappropriate billing, and ensuring compliance with contract terms and conditions. No additional details are provided regarding the contract term, renewal options, or response requirements.

View the file

Other files

File Type Posted
Attachment A Business Associate Agreement~1.pdf PDF
Attachment E CLAIM IMAGE_31SA_Redacted.pdf PDF
Attachment J CLAIM IMAGE 2AZ0_Redacted.pdf PDF
Attachment O CLAIM IMAGE _2BFJ_Redacted.pdf PDF
S000000320 High Claims Medical Bill Auditor RFP.pdf PDF
S000000320 Official Solicitation Price Sheet.xlsx XLSX spreadsheet
Attachment C CLAIM IMAGE 2JZN_Redacted.pdf PDF
Attachment K EOB IMAGE _ 1624_Redacted.pdf PDF
Attachment M CLAIM IMAGE_26K2_Redacted.pdf PDF
Attachment N CLAIM IMAGE _ 2W7N_Redacted.pdf PDF
S000000320 Contract and Grant Disclosure.pdf PDF
S000000320 Sample Services Contract.pdf PDF
S000000320 Technical Proposal Packet.docx DOCX document
Attachment G EOB 1095_Redacted.pdf PDF
Attachment H CLAIM IMAGE_3AZ6_Redacted.pdf PDF
Attachment I CLAIM IMAGE 38KY_Redacted.pdf PDF
Attachment L CLAIM IMAGE_26SP_Redacted.pdf PDF
Attachment P EOB IMAGE_0380_Redacted.pdf PDF
Attachment B Sample High Claims.pdf PDF
Attachment D CLAIM 2R72_Redacted.pdf PDF
Attachment Q EOB IMAGE_ 1791_Redacted.pdf PDF
Show all 21

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0480 3 1643.00 0483 6 5250.00 0636 768 13403.55 0637 64 697.58 0710 2 6012.00 0730 3 663.00 0921 1 1284.00

Claim Page: 2

SUBMITTER NAME INFORMATION

1000A Entity Identifier Code 41 - Submitter 1000A Entity Type Qualifier 2 - Non-Person Entity 1000A Submitter Last or Organization Name ST VINCENT HEALTH 1000A Identification Code Qualifier 46 - Electronic Transmitter Identification Number

(ETIN)

1000A Submitter Identifier 1000A Contact Function Code IC 1000A Submitter Contact Name AVAILITY CLIENT SERVICES 1000A Communication Number Qualifier TE - Telephone 1000A Communication Number 8002824548 1000A Communication Number Qualifier FX - Facsimile 1000A Communication Number 9044702187 1000A Communication Number Qualifier EM - Electronic Mail 1000A Communication Number SUPPORT@AVAILITY.COM

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... ST VINCENT HEALTH 2010AA Identification Code Qualifier XX - Centers for Medicare and Medicaid Services

National Provider Identifier 2010AA Billing Provider Identifier 2010AA Billing Provider Address Line 2 ST VINCENT CIRCLE 2010AA Billing Provider City Name LITTLE ROCK 2010AA Billing Provider State or Province ... AR 2010AA Billing Provider Postal Zone or ZIP... 722055405 2010AA Billing Provider Secondary Identifi... EI - Employer Identification Number 2010AA Billing Provider Additional Identif...

2010AA Contact Function Code IC 2010AA Billing Provider Contact Name ST VINCENT HEALTH 2010AA Communication Number Qualifier TE 2010AA Communication Number 5015523170 2010AA Communication Number Qualifier FX 2010AA Communication Number 5015524146

PAY-TO ADDRESS NAME INFORMATION

2010AB Pay-to Provider Address Line PO BOX 677712 2010AB Pay-to City Name DALLAS 2010AB Pay-to State Code TX 2010AB Pay-to Postal Zone or ZIP Code 752677712

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

CLAIM INFORMATION

2300 Total Claim Charge Amount 275620.08 2300 Facility Type Code 11 2300 Facility Code Qualifier A 2300 Claim Frequency Code 7 2300 Medicare Assignment Code A - Assigned 2300 Benefits Assignment Certification I... Y - Yes

ANSI Page: 2

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 1400 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20201209-20201215 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 202012091500

2300 TYPE OF ADMISSION 3

2300 SOURCE OF ADMISSION 2

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABK

2300 Industry Code I350

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABJ

2300 Industry Code I350

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABN

2300 Industry Code Y838

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABN

2300 Industry Code Y712

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABN

2300 Industry Code Y9289

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 219

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J9601

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I5031

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J942

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code D62

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code D689

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I97611

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I2510

ANSI Page: 3

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I340

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z87891

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I110

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E806

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code D696

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z79899

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z98890

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z954

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z951

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z888

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z7982

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z79890

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code G4730

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code D72829

2300 PRESENT ON ADMISSION INDICATOR N

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBR

2300 Industry Code 02RF08Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02UX0JZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0211093 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 06BQ4ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0WCC0ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201210

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 5A1221Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 05HM33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

ANSI Page: 4

2300 Industry Code B543ZZA 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 04HY32Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 4A133B1 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 4A133J1 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 05HB33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201214

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code B54MZZA 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201214

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0DH67UZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 3E0G76Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0W9900Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 5A1945Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0BH17EZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20201209

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 20191201

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 01 2300 Monetary Amount 636.00 2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 6.00

ANSI Page: 5

OTHER PAYER NAME INFORMATION

2330B Entity Identifier Code PR - Payer 2330B Entity Type Qualifier 2 - Non-Person Entity 2330B Other Payer Last or Organization Na... BCBS METALLIC TRUE BLUE 2330B Identification Code Qualifier PI - Payor Identification 2330B Other Payer Primary Identifier 2330B Other Subscriber Address Line PO BOX 2181 2330B Other PAYER City Name LITTLE ROCK 2330B Other PAYER State Code AR 2330B Other PAYER Postal Zone or ZIP Code 722032181

SERVICE LINE NUMBER INFORMATION

2400 Assigned Number 1

2400 INSTITUTIONAL SERVICE LINE 2400 0001SV2 0001

2400 Service Line Revenue Code 0210 2400 Line Item Charge Amount 13965.00 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 1 2400 Assigned Number 2

2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001

2400 Service Line Revenue Code 0214 2400 Line Item Charge Amount 1515.00 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 2 2400 Assigned Number 3

2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001

2400 Service Line Revenue Code 0250

ANSI Page: 6

2400 Line Item Charge Amount 13871.60 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 110 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 3 2400 Assigned Number 4

2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001

2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 6268.10 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 43 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 4 2400 Assigned Number 5

2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001

2400 Service Line Revenue Code 0259 2400 Line Item Charge Amount 1084.64 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 68 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 5 2400 Assigned Number 6

2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001

2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 2010.01 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 6 2400 Assigned Number 7

2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001

2400 Service Line Revenue Code 0271 2400 Line Item Charge Amount 6.61 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 7 2400 Assigned Number 8

2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001

2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 15972.40 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 105 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 8 2400 Assigned Number 9

2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001

2400 Service Line Revenue Code 0278 2400 Line Item Charge Amount 22590.59 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 9 2400 Assigned Number 10

2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001

2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 24360.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 198 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 10 2400 Assigned Number 11

2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001

2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 7060.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 71

ANSI Page: 7

2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 11 2400 Assigned Number 12

2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001

2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 435.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 15 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 12 2400 Assigned Number 13

2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001

2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 5131.00 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 13 2400 Assigned Number 14

2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001

2400 Service Line Revenue Code 0360 2400 Line Item Charge Amount 79089.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 451 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 14 2400 Assigned Number 15

2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001

2400 Service Line Revenue Code 0361 2400 Line Item Charge Amount 1407.00 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 15 2400 Assigned Number 16

2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001

2400 Service Line Revenue Code 0370 2400 Line Item Charge Amount 6936.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 16 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 16 2400 Assigned Number 17

2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001

2400 Service Line Revenue Code 0390 2400 Line Item Charge Amount 37788.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 32 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 17 2400 Assigned Number 18

2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001

2400 Service Line Revenue Code 0391 2400 Line Item Charge Amount 2645.00 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 18 2400 Assigned Number 19

2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001

2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 1451.00 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 19 2400 Assigned Number 20

ANSI Page: 8

2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001

2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 1967.00 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 20 2400 Assigned Number 21

2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001

2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 871.00 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 21 2400 Assigned Number 22

2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001

2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 243.00 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 22 2400 Assigned Number 23

2400 INSTITUTIONAL SERVICE LINE 2400 0023SV2 0001

2400 Service Line Revenue Code 0480 2400 Line Item Charge Amount 1643.00 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 23 2400 Assigned Number 24

2400 INSTITUTIONAL SERVICE LINE 2400 0024SV2 0001

2400 Service Line Revenue Code 0483 2400 Line Item Charge Amount 5250.00 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 24 2400 Assigned Number 25

2400 INSTITUTIONAL SERVICE LINE 2400 0025SV2 0001

2400 Service Line Revenue Code 0636 2400 Line Item Charge Amount 13403.55 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 768 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 25 2400 Assigned Number 26

2400 INSTITUTIONAL SERVICE LINE 2400 0026SV2 0001

2400 Service Line Revenue Code 0637 2400 Line Item Charge Amount 697.58 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 64 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 26 2400 Assigned Number 27

2400 INSTITUTIONAL SERVICE LINE 2400 0027SV2 0001

2400 Service Line Revenue Code 0710 2400 Line Item Charge Amount 6012.00 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 27 2400 Assigned Number 28

2400 INSTITUTIONAL SERVICE LINE 2400 0028SV2 0001

2400 Service Line Revenue Code 0730 2400 Line Item Charge Amount 663.00

ANSI Page: 9

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 28 2400 Assigned Number 29

2400 INSTITUTIONAL SERVICE LINE 2400 0029SV2 0001

2400 Service Line Revenue Code 0921 2400 Line Item Charge Amount 1284.00 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 29

ANSI Page: 10

File details come from the government source that posted it. Updated .