Attachment L CLAIM IMAGE_26SP_Redacted.pdf

352 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 state and local government contract opportunity for a High Claims Medical Bill Auditor. The opportunity covers the jurisdictions of Pulaski County and Little Rock City, Arkansas. The contract involves auditing medical bills to identify and recover overpayments. No specific details are provided regarding response dates, due dates, site visits, bidder's meetings, award dates, or contract term.

The document includes pricing information, stating the claim amounts and service units for various medical services. No additional details are provided regarding pricing terms, set asides, incumbent contractors, funding sources, or other financial information. The opportunity appears to be open for competitive bidding, but the specific procurement process is not outlined in the provided document.

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Other files

File Type Posted
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 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 F CLAIM IMAGE _ 293O_Redacted.pdf PDF
Attachment G EOB 1095_Redacted.pdf PDF
Attachment H CLAIM IMAGE_3AZ6_Redacted.pdf PDF
Attachment I CLAIM IMAGE 38KY_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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0430 13 1733.81 0460 14 6145.58

Claim Page: 2

2010AA Entity Identifier Code 85 - Billing Provider 2010AA Entity Type Qualifier 2 - Non-Person Entity 2010AA Billing Provider Last or Organizati... ARKANSAS CHILDRENS HOSPITAL 2010AA Identification Code Qualifier XX - Centers for Medicare and Medicaid Services

National Provider Identifier 2010AA Billing Provider Identifier 2010AA Billing Provider Address Line 1 CHILDRENS WAY 2010AA Billing Provider City Name LITTLE ROCK 2010AA Billing Provider State or Province ... AR 2010AA Billing Provider Postal Zone or ZIP... 722023591 2010AA Billing Provider Secondary Identifi... EI - Employer Identification Number 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 5013648100

PAY-TO ADDRESS NAME INFORMATION

2010AB Pay-to Provider Address Line PO BOX 959794 2010AB Pay-to City Name ST LOUIS 2010AB Pay-to State Code MO 2010AB Pay-to Postal Zone or ZIP Code 631959794

SUBSCRIBER INFORMATION

2000B Hierarchical ID Number 15 2000B Hierarchical Parent ID Number 1 2000B Hierarchical Level Code 22 2000B Hierarchical Child Code 1 2000B Payer Responsibility Sequence Numbe... P - Primary

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 2010BB Payer Address Line PO BOX 8069 2010BB Payer City Name LITTLE ROCK 2010BB Payer State Code AR 2010BB Payer Postal Zone or ZIP Code 722038069

CLAIM INFORMATION

2300 Total Claim Charge Amount 126920.92 2300 Facility Type Code 11 2300 Facility Code Qualifier A 2300 Claim Frequency Code 4 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 1813 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20211224-20220104 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 202112102040

2300 TYPE OF ADMISSION 1

2300 SOURCE OF ADMISSION 4

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABK

2300 Industry Code A419

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABJ

2300 Industry Code J9601

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 870

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J159

2300 PRESENT ON ADMISSION INDICATOR Y

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 J869

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R6521

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J850

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E870

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J9382

2300 PRESENT ON ADMISSION INDICATOR N

ANSI Page: 3

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J918

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E878

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Q909

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J45909

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 0002

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code H9011

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code M532X1

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E876

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code F71

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code M264

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code F419

2300 PRESENT ON ADMISSION INDICATOR Y

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 Z7951

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z8616

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBR

2300 Industry Code 0W9B30Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211216

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 5A1955Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211210

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 3E0L3GC 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211216

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 3E0L3GC 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211218

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02HV33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211211

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0W9B30Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211211

2300 CODE LIST QUALIFIER CODE BBQ

ANSI Page: 4

2300 Industry Code 0W9B30Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211224

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0BH18EZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211210

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 20211124-20211124

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 20211210

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 11.00

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BG - Condition 2300 Industry Code DR

2300 AHIN CLAIM ID QUALIFIER CI

2300 AHIN CLAIM ID 0001UB9203573952

2300 ORIGINAL POLICY ID QUALIFIER OP

2300 ORIGINAL POLICY ID NUMBER PXGY0084494102

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 220114H026SP

2300 ICN QUALIFIER - FROM PROVIDER D9

2300 BOB-ICN from provider/Dakota 220114H026SP

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... MEDICAID ARKANSAS 2330B Identification Code Qualifier PI - Payor Identification

2330B Other Subscriber Address Line PO BOX 8002 2330B Other PAYER City Name LITTLE ROCK 2330B Other PAYER State Code AR 2330B Other PAYER Postal Zone or ZIP Code 72203

SERVICE LINE NUMBER INFORMATION

2400 Assigned Number 1

2400 INSTITUTIONAL SERVICE LINE 2400 0001SV2 0001

2400 Service Line Revenue Code 0101 2400 Line Item Charge Amount 4302.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-2 2400 Assigned Number 2

2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001

2400 Service Line Revenue Code 0101 2400 Line Item Charge Amount 3002.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-1 2400 Assigned Number 3

2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001

2400 Service Line Revenue Code 0101 2400 Line Item Charge Amount 2716.00 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 1533876102-3 2400 Assigned Number 4

2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001

2400 Service Line Revenue Code 0203 2400 Line Item Charge Amount 24945.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 3 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-5 2400 Assigned Number 5

2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001

2400 Service Line Revenue Code 0203 2400 Line Item Charge Amount 18864.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-6 2400 Assigned Number 6

2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001

2400 Service Line Revenue Code 0203 2400 Line Item Charge Amount 6369.00 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 1533876102-4

ANSI Page: 6

2400 Assigned Number 7

2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001

2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 13645.79 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 546 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-7 2400 Assigned Number 8

2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001

2400 Service Line Revenue Code 0255 2400 Line Item Charge Amount 306.56 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 150 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-8 2400 Assigned Number 9

2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001

2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 320.70 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 1533876102-9 2400 Assigned Number 10

2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001

2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 2702.43 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 1533876102-10 2400 Assigned Number 11

2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001

2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 528.52 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 1533876102-11 2400 Assigned Number 12

2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001

2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 406.37 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 1533876102-12 2400 Assigned Number 13

2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001

2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 4392.35 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 20 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-13 2400 Assigned Number 14

2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001

2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 452.06 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 1533876102-14 2400 Assigned Number 15

2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001

2400 Service Line Revenue Code 0306

ANSI Page: 7

2400 Line Item Charge Amount 672.19 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 1533876102-15 2400 Assigned Number 16

2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001

2400 Service Line Revenue Code 0324 2400 Line Item Charge Amount 3164.65 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 11 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-16 2400 Assigned Number 17

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2400 Service Line Revenue Code 0350 2400 Line Item Charge Amount 2227.27 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 1533876102-17 2400 Assigned Number 18

2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001

2400 Service Line Revenue Code 0361 2400 Line Item Charge Amount 5985.17 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 1533876102-18 2400 Assigned Number 19

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2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 1014.90 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 1533876102-20 2400 Assigned Number 21

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2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 19888.56 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 1533876102-21 2400 Assigned Number 22

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2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 2019.60 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 1533876102-22 2400 Assigned Number 23

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2400 Service Line Revenue Code 0430 2400 Line Item Charge Amount 1733.81 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 13

ANSI Page: 8

2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1533876102-23 2400 Assigned Number 24

2400 INSTITUTIONAL SERVICE LINE 2400 0024SV2 0001

2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 6145.58 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 1533876102-24

ANSI Page: 9

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