Attachment M CLAIM IMAGE_26K2_Redacted.pdf

237 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 an ANSI 837 Institutional Health Care Claim file related to a medical claim submitted to Arkansas Blue Cross Blue Shield by NEA Baptist Memorial Hospital. The claim details the treatment and services provided to a patient, including a variety of medical procedures and supplies with associated revenue codes, charge amounts, and service dates. The jurisdictions involved are Pulaski County and the City of Little Rock, Arkansas.

The document provides extensive claim-level details and supporting diagnostic and procedural codes but does not contain any information about a state or local contract opportunity. There are no details about a solicitation, services requested, response requirements, or contract terms. The document appears to be focused solely on the specifics of a medical insurance claim rather than a procurement opportunity.

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 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 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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0460 27 5511.00 0.00 0480 1 1164.00 0.00 0621 3 432.00 0.00 0636 9999 86764.00 0.00 0710 2 2444.00 0.00 0730 3 888.00 0.00 0801 14 14490.00 0.00 0803 6 8376.00 0.00 0921 2 1430.00 0.00 0940 19 2394.00 0.00

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

National Provider Identifier 2010AA Billing Provider Identifier 2010AA Billing Provider Address Line 4800 EAST JOHNSON AVE 2010AA Billing Provider City Name JONESBORO 2010AA Billing Provider State or Province ... AR 2010AA Billing Provider Postal Zone or ZIP... 724058413 2010AA Billing Provider Secondary Identifi... EI - Employer Identification Number 2010AA Billing Provider Additional Identif...

2010AA Contact Function Code IC 2010AA Billing Provider Contact Name NEA 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 849123 2010AB Pay-to City Name DALLAS 2010AB Pay-to State Code TX 2010AB Pay-to Postal Zone or ZIP Code 752849123

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 2010BB Payer Address Line PO BOX 2181 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 583655.56 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 1008 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20211213-20220128 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 202112131255

2300 TYPE OF ADMISSION 3

2300 SOURCE OF ADMISSION 1

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABK

2300 Industry Code E6601

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABJ

2300 Industry Code E6601

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABN

2300 Industry Code X58XXXA

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 619

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J9601

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J189

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code A419

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R6521

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I2699

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code N170

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I469

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 N184

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

ANSI Page: 3

2300 Industry Code Z20822

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z6843

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E1140

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z8616

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z9981

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E7800

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code G4733

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Z7984

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E1122

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I129

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R609

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code S301XXA

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R5381

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code F419

2300 PRESENT ON ADMISSION INDICATOR N

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBR

2300 Industry Code 0DB64Z3 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211213

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0BH18EZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211216

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 5A1955Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211216

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0B9C8ZX 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211216

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02HV33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211216

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 05HM33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211222

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 5A1D90Z 2300 Date Time Period Format Qualifier D8

ANSI Page: 4

2300 Date Time Period 20211222

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 06H03DZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211227

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02H633Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211227

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 0JH63XZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20220119

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 02HV33Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20220119

2300 CODE LIST QUALIFIER CODE BBQ

2300 Industry Code 5A12012 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211217

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 20211213 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 11 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211213 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 17 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211213 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 29 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211213 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 35 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211213 2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 44 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211213

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

2300 AHIN CLAIM ID QUALIFIER CI

2300 AHIN CLAIM ID 0001UB92035A685B

2300 ORIGINAL POLICY ID QUALIFIER OP

2300 ORIGINAL POLICY ID NUMBER PXGY0021006201

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 220209H026K2

2300 ICN QUALIFIER - FROM PROVIDER D9

2300 BOB-ICN from provider/Dakota 220209H026K2

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 2544.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 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 420223438900-1 2400 Assigned Number 2

2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001

2400 Service Line Revenue Code 0110 2400 Line Item Charge Amount 18504.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 18 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 420223438900-2 2400 Assigned Number 3

2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001

2400 Service Line Revenue Code 0200 2400 Line Item Charge Amount 46225.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 25 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 420223438900-3 2400 Assigned Number 4

2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001

2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 115193.22 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 920 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 420223438900-4 2400 Assigned Number 5

2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001

ANSI Page: 6

2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 25711.40 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 195 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 420223438900-5 2400 Assigned Number 6

2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001

2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 4344.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 8 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 420223438900-6 2400 Assigned Number 7

2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001

2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 6880.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 20 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 420223438900-7 2400 Assigned Number 8

2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001

2400 Service Line Revenue Code 0278 2400 Line Item Charge Amount 4466.91 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 420223438900-8 2400 Assigned Number 9

2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001

2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 79006.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 390 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 420223438900-9 2400 Assigned Number 10

2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001

2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 10284.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 21 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 420223438900-10 2400 Assigned Number 11

2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001

2400 Service Line Revenue Code 0352 2400 Line Item Charge Amount 18936.03 2400 BASIS FOR MEASUREMENT CODE UN - Unit 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 420223438900-11 2400 Assigned Number 12

2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001

2400 Service Line Revenue Code 0360 2400 Line Item Charge Amount 12885.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9

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 420223438900-12 2400 Assigned Number 13

2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001

2400 Service Line Revenue Code 0361 2400 Line Item Charge Amount 18923.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 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 420223438900-13 2400 Assigned Number 14

2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001

2400 Service Line Revenue Code 0370 2400 Line Item Charge Amount 3655.00 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 420223438900-14 2400 Assigned Number 15

2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001

2400 Service Line Revenue Code 0390 2400 Line Item Charge Amount 5874.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 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 420223438900-15 2400 Assigned Number 16

2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001

2400 Service Line Revenue Code 0391 2400 Line Item Charge Amount 2550.00 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 420223438900-16 2400 Assigned Number 17

2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001

2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 933.00 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 420223438900-17 2400 Assigned Number 18

2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001

2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 47475.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 124 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 420223438900-18 2400 Assigned Number 19

2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001

2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 29997.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 133 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 420223438900-19 2400 Assigned Number 20

ANSI Page: 8

2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001

2400 Service Line Revenue Code 0424 2400 Line Item Charge Amount 539.00 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 420223438900-20 2400 Assigned Number 21

2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001

2400 Service Line Revenue Code 0430 2400 Line Item Charge Amount 4323.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 40 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 420223438900-21 2400 Assigned Number 22

2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001

2400 Service Line Revenue Code 0434 2400 Line Item Charge Amount 514.00 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 420223438900-22 2400 Assigned Number 23

2400 INSTITUTIONAL SERVICE LINE 2400 0023SV2 0001

2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 5511.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 27 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 420223438900-23 2400 Assigned Number 24

2400 INSTITUTIONAL SERVICE LINE 2400 0024SV2 0001

2400 Service Line Revenue Code 0480 2400 Line Item Charge Amount 1164.00 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 420223438900-24 2400 Assigned Number 25

2400 INSTITUTIONAL SERVICE LINE 2400 0025SV2 0001

2400 Service Line Revenue Code 0621 2400 Line Item Charge Amount 432.00 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 420223438900-25 2400 Assigned Number 26

2400 INSTITUTIONAL SERVICE LINE 2400 0026SV2 0001

2400 Service Line Revenue Code 0636 2400 Line Item Charge Amount 86764.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9999 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 420223438900-26 2400 Assigned Number 27

2400 INSTITUTIONAL SERVICE LINE 2400 0027SV2 0001

2400 Service Line Revenue Code 0710 2400 Line Item Charge Amount 2444.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit

ANSI Page: 9

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 420223438900-27 2400 Assigned Number 28

2400 INSTITUTIONAL SERVICE LINE 2400 0028SV2 0001

2400 Service Line Revenue Code 0730 2400 Line Item Charge Amount 888.00 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 420223438900-28 2400 Assigned Number 29

2400 INSTITUTIONAL SERVICE LINE 2400 0029SV2 0001

2400 Service Line Revenue Code 0801 2400 Line Item Charge Amount 14490.00 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 420223438900-29 2400 Assigned Number 30

2400 INSTITUTIONAL SERVICE LINE 2400 0030SV2 0001

2400 Service Line Revenue Code 0803 2400 Line Item Charge Amount 8376.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 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 420223438900-30 2400 Assigned Number 31

2400 INSTITUTIONAL SERVICE LINE 2400 0031SV2 0001

2400 Service Line Revenue Code 0921 2400 Line Item Charge Amount 1430.00 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 420223438900-31 2400 Assigned Number 32

2400 INSTITUTIONAL SERVICE LINE 2400 0032SV2 0001

2400 Service Line Revenue Code 0940 2400 Line Item Charge Amount 2394.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 19 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 420223438900-32

ANSI Page: 10

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