Attachment I CLAIM IMAGE 38KY_Redacted.pdf
PDF 3 MB 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 for Pulaski County and the City of Little Rock. The document contains detailed line item claims data for a medical claim, including revenue codes, service line details, and charge amounts. The total claim amount is over $228,000. The contract opportunity involves providing auditing services for high medical claims in the specified jurisdictions.
The contract appears to be open to all qualified bidders, with no mention of any set-asides or incumbent contractors. The document does not provide details on the pricing terms, funding requirements, or other salient commercial information. However, it does indicate that this is an active contract opportunity in the state of Arkansas for the specified local government entities.
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Text version
0420 7 710.00 0424 1 182.00 0440 8 1656.00 0444 1 387.00 0460 34 4801.00 0471 1 309.00 0611 1 2643.00 0636 134 8637.13 0761 1 168.00 0920 2 182.00 0940 14 3489.00
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 HEAD Interchange Date 211207 HEAD Interchange Time 1432 HEAD Interchange Control Standards ID { HEAD Interchange Control Version Number 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 HEAD Date 20211207 HEAD Time 14320000 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 20211207 HEAD Transaction Set Creation Time 14320000 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 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
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 0816 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20210901-20211021 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 202109011103
2300 TYPE OF ADMISSION 4
2300 SOURCE OF ADMISSION 5
2300 PATIENT STATUS CODE 01
2300 Reference Identification Qualifier 9F - Referral Number 2300 Reference Identification Number 2300 Reference Identification Qualifier G1 - Prior Authorization 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 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABK
2300 Industry Code Z3800
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABJ
2300 Industry Code Z3800
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 790
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P220
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P5221
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P284
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P612
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P0715
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 P0732
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Q826
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P929
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code H35113
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P545
2300 PRESENT ON ADMISSION INDICATOR N
ANSI Page: 3
2400 Assigned Number 1
2400 INSTITUTIONAL SERVICE LINE 2400 0001SV2 0001
2400 Service Line Revenue Code 0172 2400 Line Item Charge Amount 122978.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 34 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-1 2400 Assigned Number 2
2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001
2400 Service Line Revenue Code 0173 2400 Line Item Charge Amount 57600.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 12 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-2 2400 Assigned Number 3
2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 23540.00 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 H7420007280704-3 2400 Assigned Number 4
2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001
2400 Service Line Revenue Code 0220 2400 Line Item Charge Amount 228.00 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 H7420007280704-4 2400 Assigned Number 5
2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001
2400 Service Line Revenue Code 0231 2400 Line Item Charge Amount 138.00 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 H7420007280704-5 2400 Assigned Number 6
2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001
2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 5431.09 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 176 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-6 2400 Assigned Number 7
2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001
2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 1195.30 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 H7420007280704-7 2400 Assigned Number 8
2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001
2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 9646.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 242 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-8 2400 Assigned Number 9
2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001
2400 Service Line Revenue Code 0272
ANSI Page: 5
2400 Line Item Charge Amount 1135.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 126 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-9 2400 Assigned Number 10
2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001
2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 380.00 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 H7420007280704-10 2400 Assigned Number 11
2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001
2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 9040.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 103 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-11 2400 Assigned Number 12
2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001
2400 Service Line Revenue Code 0302 2400 Line Item Charge Amount 447.00 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 H7420007280704-12 2400 Assigned Number 13
2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001
2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 1437.00 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 H7420007280704-13 2400 Assigned Number 14
2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001
2400 Service Line Revenue Code 0306 2400 Line Item Charge Amount 155.00 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 H7420007280704-14 2400 Assigned Number 15
2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001
2400 Service Line Revenue Code 0310 2400 Line Item Charge Amount 54.00 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 H7420007280704-15 2400 Assigned Number 16
2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001
2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 843.00 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 H7420007280704-16 2400 Assigned Number 17
2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001
2400 Service Line Revenue Code 0324 2400 Line Item Charge Amount 965.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5
ANSI Page: 6
2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-17 2400 Assigned Number 18
2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001
2400 Service Line Revenue Code 0341 2400 Line Item Charge Amount 1372.00 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 H7420007280704-18 2400 Assigned Number 19
2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001
2400 Service Line Revenue Code 0343 2400 Line Item Charge Amount 141.00 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 H7420007280704-19 2400 Assigned Number 20
2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001
2400 Service Line Revenue Code 0360 2400 Line Item Charge Amount 1368.00 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 H7420007280704-20 2400 Assigned Number 21
2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001
2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 4089.00 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 H7420007280704-21 2400 Assigned Number 22
2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001
2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 3965.00 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 H7420007280704-22 2400 Assigned Number 23
2400 INSTITUTIONAL SERVICE LINE 2400 0023SV2 0001
2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 710.00 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 H7420007280704-23 2400 Assigned Number 24
2400 INSTITUTIONAL SERVICE LINE 2400 0024SV2 0001
2400 Service Line Revenue Code 0424 2400 Line Item Charge Amount 182.00 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 H7420007280704-24 2400 Assigned Number 25
2400 INSTITUTIONAL SERVICE LINE 2400 0025SV2 0001
2400 Service Line Revenue Code 0440 2400 Line Item Charge Amount 1656.00 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 H7420007280704-25 2400 Assigned Number 26
ANSI Page: 7
2400 INSTITUTIONAL SERVICE LINE 2400 0026SV2 0001
2400 Service Line Revenue Code 0444 2400 Line Item Charge Amount 387.00 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 H7420007280704-26 2400 Assigned Number 27
2400 INSTITUTIONAL SERVICE LINE 2400 0027SV2 0001
2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 4801.00 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 H7420007280704-27 2400 Assigned Number 28
2400 INSTITUTIONAL SERVICE LINE 2400 0028SV2 0001
2400 Service Line Revenue Code 0471 2400 Line Item Charge Amount 309.00 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 H7420007280704-28 2400 Assigned Number 29
2400 INSTITUTIONAL SERVICE LINE 2400 0029SV2 0001
2400 Service Line Revenue Code 0611 2400 Line Item Charge Amount 2643.00 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 H7420007280704-29 2400 Assigned Number 30
2400 INSTITUTIONAL SERVICE LINE 2400 0030SV2 0001
2400 Service Line Revenue Code 0636 2400 Line Item Charge Amount 8637.13 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 134 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-30 2400 Assigned Number 31
2400 INSTITUTIONAL SERVICE LINE 2400 0031SV2 0001
2400 Service Line Revenue Code 0761 2400 Line Item Charge Amount 168.00 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 H7420007280704-31 2400 Assigned Number 32
2400 INSTITUTIONAL SERVICE LINE 2400 0032SV2 0001
2400 Service Line Revenue Code 0920 2400 Line Item Charge Amount 182.00 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 H7420007280704-32 2400 Assigned Number 33
2400 INSTITUTIONAL SERVICE LINE 2400 0033SV2 0001
2400 Service Line Revenue Code 0940 2400 Line Item Charge Amount 3489.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 14 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number H7420007280704-33
ANSI Page: 8
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