Attachment H CLAIM IMAGE_3AZ6_Redacted.pdf

236 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 appears to be a medical claim attachment related to a contract opportunity for a high claims medical bill auditor for Pulaski County and the City of Little Rock in Arkansas.

The claim attachment provides detailed line-item information on medical services and charges for a specific patient. The contract opportunity seeks a vendor to audit high claims medical bills for the local government jurisdictions. Key details include the need for auditing and reviewing medical claims, with potential service line items spanning various medical procedures and revenue codes. No specific quantities, response dates, award dates, or contract term details are provided in the given information.

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 F CLAIM IMAGE _ 293O_Redacted.pdf PDF
Attachment G EOB 1095_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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0424 3 1920.00 0.00 0430 24 4266.00 0.00 0434 2 1530.00 0.00 0450 1 2568.00 0.00 0481 1 12086.00 0.00 0483 1 3389.00 0.00 0622 2 279.00 0.00 0636 3731 16014.93 0.00 0710 2 1814.00 0.00 0730 4 1446.00 0.00 0771 2 204.00 0.00 0921 2 1797.00 0.00

Claim Page: 2

TRANSACTION SET HEADER

SUBMITTER NAME INFORMATION

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

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... BAPTIST MEMORIAL HOSPITAL 2010AA Identification Code Qualifier XX - Centers for Medicare and Medicaid Services

National Provider Identifier 2010AA Billing Provider Identifier 1578527172 2010AA Billing Provider Address Line 6225 HUMPHREYS BLVD 2010AA Billing Provider City Name MEMPHIS 2010AA Billing Provider State or Province ... TN 2010AA Billing Provider Postal Zone or ZIP... 381202373 2010AA Billing Provider Secondary Identifi... EI - Employer Identification Number 2010AA Billing Provider Additional Identif... 620123940 2010AA Contact Function Code IC 2010AA Billing Provider Contact Name BAPTIST MEMORIAL HOSPITAL 2010AA Communication Number Qualifier TE 2010AA Communication Number 8004115433

PAY-TO ADDRESS NAME INFORMATION

2010AB Pay-to Provider Address Line PO BOX 1000 2010AB Pay-to Provider Address Line DEPT 157 2010AB Pay-to City Name MEMPHIS 2010AB Pay-to State Code TN 2010AB Pay-to Postal Zone or ZIP Code 381480157

SUBSCRIBER INFORMATION

2000B Hierarchical ID Number 3 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 2000B Claim Filing Indicator Code BL - Blue Cross Blue Shield

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 P O BOX 2181 2010BB Payer City Name LITTLE ROCK 2010BB Payer State Code AR 2010BB Payer Postal Zone or ZIP Code 722032181

CLAIM INFORMATION

2300 Total Claim Charge Amount 423323.41 2300 Facility Type Code 11

ANSI Page: 2

2300 Facility Code Qualifier A 2300 Claim Frequency Code 1 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 2018 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date

2300 TYPE OF ADMISSION 1

2300 SOURCE OF ADMISSION 1

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABK

2300 Industry Code C786

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABJ

2300 Industry Code I213

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABN

2300 Industry Code Y838

2300 PRESENT ON ADMISSION INDICATOR N

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 335

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I213

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code K661

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code D61810

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code N170

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I82433

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I82453

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I82443

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code D84821

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E872

2300 PRESENT ON ADMISSION INDICATOR Y

ANSI Page: 3

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code C7951

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code T8149XA

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code K922

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code C7989

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code T8131XA

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code T8183XA

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R7881

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R188

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J9811

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z23

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z20822

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code C61

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E119

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R000

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBR

2300 Industry Code 0DNU0ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211006

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0DNL0ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211006

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0DBU0ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211006

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02H633Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210928

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 4A023N7 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code B2111ZZ 2300 Date Time Period Format Qualifier D8

ANSI Page: 4

2300 Date Time Period 20210927

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0DHA3UZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211006

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02HV33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211005

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 3E0436Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211015

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 05 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 11 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 17 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 29 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 35 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 44 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 02 2300 Monetary Amount 0.00 2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 46.00

SERVICE LINE NUMBER INFORMATION

2400 Assigned Number 1

2400 INSTITUTIONAL SERVICE LINE 2400 0001SV2 0001

2400 Service Line Revenue Code 0110 2400 Line Item Charge Amount 20174.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 14 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-1 2400 Assigned Number 2

2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001

2400 Service Line Revenue Code 0110 2400 Line Item Charge Amount 34464.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 16 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-2 2400 Assigned Number 3

2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001

2400 Service Line Revenue Code 0200 2400 Line Item Charge Amount 4628.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 1 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-3 2400 Assigned Number 4

2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001

2400 Service Line Revenue Code 0206 2400 Line Item Charge Amount 21270.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 6 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-4 2400 Assigned Number 5

2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001

2400 Service Line Revenue Code 0210 2400 Line Item Charge Amount 8900.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-5 2400 Assigned Number 6

2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001

ANSI Page: 6

2400 Service Line Revenue Code 0214 2400 Line Item Charge Amount 6818.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-6 2400 Assigned Number 7

2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001

2400 Service Line Revenue Code 0214 2400 Line Item Charge Amount 17725.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 5 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-7 2400 Assigned Number 8

2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001

2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 46942.32 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1343 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-8 2400 Assigned Number 9

2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001

2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 11102.10 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 161 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-9 2400 Assigned Number 10

2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001

2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 7968.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 16 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-10 2400 Assigned Number 11

2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001

2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 5990.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 13 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-11 2400 Assigned Number 12

2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001

2400 Service Line Revenue Code 0278 2400 Line Item Charge Amount 1230.02 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-12 2400 Assigned Number 13

2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001

2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 77680.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 337

ANSI Page: 7

2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-13 2400 Assigned Number 14

2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001

2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 3796.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 11 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-14 2400 Assigned Number 15

2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001

2400 Service Line Revenue Code 0352 2400 Line Item Charge Amount 24109.04 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-15 2400 Assigned Number 16

2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001

2400 Service Line Revenue Code 0360 2400 Line Item Charge Amount 30268.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 14 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-16 2400 Assigned Number 17

2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001

2400 Service Line Revenue Code 0361 2400 Line Item Charge Amount 5455.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-17 2400 Assigned Number 18

2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001

2400 Service Line Revenue Code 0370 2400 Line Item Charge Amount 5422.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 7 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-18 2400 Assigned Number 19

2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001

2400 Service Line Revenue Code 0390 2400 Line Item Charge Amount 24041.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-19 2400 Assigned Number 20

2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001

2400 Service Line Revenue Code 0391 2400 Line Item Charge Amount 2172.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-20 2400 Assigned Number 21

ANSI Page: 8

2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001

2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 1034.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-21 2400 Assigned Number 22

2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001

2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 14821.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 72 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-22 2400 Assigned Number 23

2400 INSTITUTIONAL SERVICE LINE 2400 0023SV2 0001

2400 Service Line Revenue Code 0424 2400 Line Item Charge Amount 1920.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 3 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-23 2400 Assigned Number 24

2400 INSTITUTIONAL SERVICE LINE 2400 0024SV2 0001

2400 Service Line Revenue Code 0430 2400 Line Item Charge Amount 4266.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 24 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-24 2400 Assigned Number 25

2400 INSTITUTIONAL SERVICE LINE 2400 0025SV2 0001

2400 Service Line Revenue Code 0434 2400 Line Item Charge Amount 1530.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-25 2400 Assigned Number 26

2400 INSTITUTIONAL SERVICE LINE 2400 0026SV2 0001

2400 Service Line Revenue Code 0450 2400 Line Item Charge Amount 2568.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-26 2400 Assigned Number 27

2400 INSTITUTIONAL SERVICE LINE 2400 0027SV2 0001

2400 Service Line Revenue Code 0481 2400 Line Item Charge Amount 12086.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-27 2400 Assigned Number 28

2400 INSTITUTIONAL SERVICE LINE 2400 0028SV2 0001

2400 Service Line Revenue Code 0483 2400 Line Item Charge Amount 3389.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit

ANSI Page: 9

2400 Service Unit Count 1 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-28 2400 Assigned Number 29

2400 INSTITUTIONAL SERVICE LINE 2400 0029SV2 0001

2400 Service Line Revenue Code 0622 2400 Line Item Charge Amount 279.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-29 2400 Assigned Number 30

2400 INSTITUTIONAL SERVICE LINE 2400 0030SV2 0001

2400 Service Line Revenue Code 0636 2400 Line Item Charge Amount 16014.93 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 3731 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-30 2400 Assigned Number 31

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2400 Service Line Revenue Code 0710 2400 Line Item Charge Amount 1814.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-31 2400 Assigned Number 32

2400 INSTITUTIONAL SERVICE LINE 2400 0032SV2 0001

2400 Service Line Revenue Code 0730 2400 Line Item Charge Amount 1446.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 4 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-32 2400 Assigned Number 33

2400 INSTITUTIONAL SERVICE LINE 2400 0033SV2 0001

2400 Service Line Revenue Code 0771 2400 Line Item Charge Amount 204.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-33 2400 Assigned Number 34

2400 INSTITUTIONAL SERVICE LINE 2400 0034SV2 0001

2400 Service Line Revenue Code 0921 2400 Line Item Charge Amount 1797.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Denied Charge or Non-Cove... 0.00 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 210371672201-34

ANSI Page: 10

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