Attachment J CLAIM IMAGE 2AZ0_Redacted.pdf

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 211213 HEAD Interchange Time 1831 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 20211213 HEAD Time 18310000 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 20211213 HEAD Transaction Set Creation Time 18310000 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

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...

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 92 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 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 1529871700 2300 Total Claim Charge Amount 162601.24 2300 Facility Type Code 11 2300 Facility Code Qualifier A

ANSI Page: 2

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 1820 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20211130-20211204 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 202111302050

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 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 I471

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABJ

2300 Industry Code I471

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 273

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I400

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code U099

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R002

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R110

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I493

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z20822

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBR

2300 Industry Code 02563ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211202

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 4A0234Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211202

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02K83ZZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211202

ANSI Page: 3

2400 Assigned Number 4

2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001

2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 53.45 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 1529871700-4 2400 Assigned Number 5

2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001

2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 3591.50 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 1529871700-5 2400 Assigned Number 6

2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001

2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 16546.62 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 1529871700-6 2400 Assigned Number 7

2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001

2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 296.00 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 1529871700-7 2400 Assigned Number 8

2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001

2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 2036.04 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 1529871700-8 2400 Assigned Number 9

2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001

2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 260.19 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 1529871700-9 2400 Assigned Number 10

2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001

2400 Service Line Revenue Code 0306 2400 Line Item Charge Amount 349.22 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 1529871700-10 2400 Assigned Number 11

2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001

2400 Service Line Revenue Code 0361 2400 Line Item Charge Amount 2763.12 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 1529871700-11 2400 Assigned Number 12

2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001

2400 Service Line Revenue Code 0370

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2400 Line Item Charge Amount 1857.96 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 1529871700-12 2400 Assigned Number 13

2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001

2400 Service Line Revenue Code 0450 2400 Line Item Charge Amount 1813.50 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 1529871700-13 2400 Assigned Number 14

2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001

2400 Service Line Revenue Code 0480 2400 Line Item Charge Amount 63162.10 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 1529871700-14 2400 Assigned Number 15

2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001

2400 Service Line Revenue Code 0481 2400 Line Item Charge Amount 2900.88 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 1529871700-15 2400 Assigned Number 16

2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001

2400 Service Line Revenue Code 0483 2400 Line Item Charge Amount 1466.61 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 1529871700-16 2400 Assigned Number 17

2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001

2400 Service Line Revenue Code 0730 2400 Line Item Charge Amount 667.10 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 1529871700-17

ANSI Page: 6