Attachment N CLAIM IMAGE _ 2W7N_Redacted.pdf
PDF 216 KB 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 targeting the jurisdictions of Pulaski County and Little Rock City. The document contains detailed claim information, including billing provider, payer, and healthcare diagnosis data. The contract opportunity is seeking an expert in reviewing and auditing high-value medical claims to identify potential overpayments or billing errors. The contract term and any renewal options are not specified in the information provided.
The attachment provides extensive details on the claim, including service line items, revenue codes, charge amounts, and units of service. Pricing terms, set-asides, incumbent information, funding sources, and other salient financial details are not included in the provided documentation. The contract opportunity appears to focus on thorough review and analysis of complex medical claims to ensure accurate payments by the state and local government entities.
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SUBMITTER NAME INFORMATION
1000A Entity Identifier Code 41 - Submitter 1000A Entity Type Qualifier 2 - Non-Person Entity 1000A Submitter Last or Organization Name THE SSI GROUP 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
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... 710236857 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 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
ANSI Page: 1
2000B Hierarchical ID Number 29 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 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 105575.34 2300 Facility Type Code 11 2300 Facility Code Qualifier A 2300 Claim Frequency Code 7 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 1348 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20211227-20220112 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 202112271543
2300 TYPE OF ADMISSION 1
2300 SOURCE OF ADMISSION 4
ANSI Page: 2
2300 Note Reference Code ADD - Additional Information 2300 Claim Note Text CORRECTED CLAIM
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABK
2300 Industry Code P9689
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABJ
2300 Industry Code R140
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 P0703
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Q620
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 I898
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code K668
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P0717
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P0737
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P2889
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P922
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P7883
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P030
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Z051
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002
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 0W9G3ZX 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211228
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 20211215-20211227
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
ANSI Page: 3
2300 Date Time Period 20211227
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 16.00
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BG - Condition 2300 Industry Code D1 2300 CODE LIST QUALIFIER CODE BG - Condition 2300 Industry Code DR
SERVICE LINE NUMBER INFORMATION
2400 Assigned Number 1
2400 INSTITUTIONAL SERVICE LINE 2400 0001SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 79888.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 16 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1538454103-1 2400 Assigned Number 2
2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001
2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 4746.86 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 446 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1538454103-2 2400 Assigned Number 3
2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001
2400 Service Line Revenue Code 0255 2400 Line Item Charge Amount 108.92 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 101 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1538454103-3 2400 Assigned Number 4
ANSI Page: 4
2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001
2400 Service Line Revenue Code 0260 2400 Line Item Charge Amount 317.55 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 1538454103-4 2400 Assigned Number 5
2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001
2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 59.87 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 1538454103-5 2400 Assigned Number 6
2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001
2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 246.07 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 1538454103-6 2400 Assigned Number 7
2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001
2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 1282.01 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 26 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1538454103-7 2400 Assigned Number 8
2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001
2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 4238.66 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 21 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1538454103-8 2400 Assigned Number 9
2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001
2400 Service Line Revenue Code 0302 2400 Line Item Charge Amount 222.30 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 1538454103-9 2400 Assigned Number 10
2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001
2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 706.16 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 1538454103-10 2400 Assigned Number 11
2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001
2400 Service Line Revenue Code 0306 2400 Line Item Charge Amount 773.62 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 1538454103-11 2400 Assigned Number 12
2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001
2400 Service Line Revenue Code 0310 2400 Line Item Charge Amount 6.63
ANSI Page: 5
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 1538454103-12 2400 Assigned Number 13
2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001
2400 Service Line Revenue Code 0311 2400 Line Item Charge Amount 262.95 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 1538454103-13 2400 Assigned Number 14
2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001
2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 2481.98 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 1538454103-14 2400 Assigned Number 15
2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001
2400 Service Line Revenue Code 0324 2400 Line Item Charge Amount 326.15 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 1538454103-15 2400 Assigned Number 16
2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001
2400 Service Line Revenue Code 0390 2400 Line Item Charge Amount 46.50 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 30 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1538454103-16 2400 Assigned Number 17
2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001
2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 1386.29 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 1538454103-17 2400 Assigned Number 18
2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001
2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 551.71 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 1538454103-18 2400 Assigned Number 19
2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001
2400 Service Line Revenue Code 0430 2400 Line Item Charge Amount 307.07 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 1538454103-19 2400 Assigned Number 20
2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001
2400 Service Line Revenue Code 0470 2400 Line Item Charge Amount 1981.56 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 8 2400 Line Item Control Number 6R - Provider Control Number
ANSI Page: 6
2400 Repriced Line Item Reference Number 1538454103-20 2400 Assigned Number 21
2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001
2400 Service Line Revenue Code 0610 2400 Line Item Charge Amount 3673.12 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 1538454103-21 2400 Assigned Number 22
2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001
2400 Service Line Revenue Code 0761 2400 Line Item Charge Amount 1961.36 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 1538454103-22
ANSI Page: 7
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