Attachment O CLAIM IMAGE _2BFJ_Redacted.pdf
PDF 1 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 medical claim for a state and local contract opportunity in Arkansas. The contract opportunity is for a High Claims Medical Bill Auditor, covering the jurisdictions of Pulaski County and Little Rock City.
The key details indicate this is a medical claim submission from Arkansas Children's Hospital to the Arkansas Blue Cross Blue Shield payer, with secondary coverage from Medicaid Arkansas. The claim includes a detailed listing of medical service line items with associated charge amounts, service units, revenue codes, and other relevant billing information. While no specific details on the contract opportunity are provided, this document appears to be relevant to the audit services being requested.
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Text version
0360 6 7706.07 0361 1 2301.68 0370 18 3911.52 0390 372 576.60 0402 14 10068.28 0410 9999 490134.52 0420 28 4436.71 0430 14 2040.88 0460 20 7242.56 0470 25 5713.49 0481 1 5760.51 0483 36 29279.81 0610 2 6178.54 0771 5 2293.25 0920 332 15797.47 0921 5 2729.00
Claim Page: 2
TRANSACTION SET HEADER
SUBMITTER NAME INFORMATION
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
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
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...
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
ANSI Page: 1
2000B Hierarchical ID Number 48 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 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 1984608.24 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 1615 2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20210726-20220131 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 202107260156
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 P285
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE ABJ
2300 Industry Code P285
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 P0724
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P5222
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P610
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P912
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P772
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P612
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Q250
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Q211
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P284
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code J9382
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P7441
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P271
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code J0410
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code I959
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code Q030
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code H35113
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P2810
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P021
2300 PRESENT ON ADMISSION INDICATOR Y
ANSI Page: 3
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code G9389
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 B9562
2300 PRESENT ON ADMISSION INDICATOR N
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P7421
2300 PRESENT ON ADMISSION INDICATOR Y
2300 CODE LIST QUALIFIER CODE ABF
2300 Industry Code P590
2300 PRESENT ON ADMISSION INDICATOR Y
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BBR
2300 Industry Code 00160J6 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210927
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 02LR3DT 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210827
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 4A023N6 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210827
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 0DH63UZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211220
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 009U3ZX 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210819
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 009U3ZX 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211223
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 5A1955Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210726
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 06H033Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20220111
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code B519ZZA 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20220111
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 0BH18EZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210726
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 02H633Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210730
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 03HY32Z 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210810
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 0BH17EZ
ANSI Page: 4
2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20210818
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002
2300 CODE LIST QUALIFIER CODE BBQ
2300 Industry Code 0BH18EZ 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20211119
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 20210725-20210725
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 20210725
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 189.00
2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001
2300 CODE LIST QUALIFIER CODE BG - Condition 2300 Industry Code DR
OTHER SUBSCRIBER INFORMATION
2320 Payer Responsibility Sequence Numbe... S - Secondary 2320 Individual Relationship Code 18 - Self 2320 Insurance Type Code MC 2320 Benefits Assignment Certification I... Y 2320 Patient Signature Source Code Y
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 Payer Primary Identifier 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 0174 2400 Line Item Charge Amount 903792.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 152 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-3 2400 Assigned Number 2
2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 174755.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 35 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-2 2400 Assigned Number 3
2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 7301.00 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 1487102027-4 2400 Assigned Number 4
2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001
2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 3901.00 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 1487102027-1 2400 Assigned Number 5
2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001
2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 101093.12 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9999 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-5 2400 Assigned Number 6
2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001
2400 Service Line Revenue Code 0255 2400 Line Item Charge Amount 159.38 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 1487102027-6
ANSI Page: 6
2400 Assigned Number 7
2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001
2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 59.96 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 1487102027-7 2400 Assigned Number 8
2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001
2400 Service Line Revenue Code 0260 2400 Line Item Charge Amount 1167.60 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 1487102027-8 2400 Assigned Number 9
2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001
2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 6510.64 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 1487102027-9 2400 Assigned Number 10
2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001
2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 3898.26 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 60 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-10 2400 Assigned Number 11
2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001
2400 Service Line Revenue Code 0274 2400 Line Item Charge Amount 53.48 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 1487102027-11 2400 Assigned Number 12
2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001
2400 Service Line Revenue Code 0278 2400 Line Item Charge Amount 22887.50 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 1487102027-12 2400 Assigned Number 13
2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001
2400 Service Line Revenue Code 0300 2400 Line Item Charge Amount 5067.58 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 88 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-13 2400 Assigned Number 14
2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001
2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 90660.16 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 391 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-14 2400 Assigned Number 15
2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001
2400 Service Line Revenue Code 0302
ANSI Page: 7
2400 Line Item Charge Amount 1681.51 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 22 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-15 2400 Assigned Number 16
2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001
2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 7137.86 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 119 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-16 2400 Assigned Number 17
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2400 Service Line Revenue Code 0306 2400 Line Item Charge Amount 9366.50 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 48 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-17 2400 Assigned Number 18
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2400 Service Line Revenue Code 0307 2400 Line Item Charge Amount 118.22 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 1487102027-18 2400 Assigned Number 19
2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001
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2400 INSTITUTIONAL SERVICE LINE 2400 0020SV2 0001
2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 12686.82 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 44 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-20 2400 Assigned Number 21
2400 INSTITUTIONAL SERVICE LINE 2400 0021SV2 0001
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2400 INSTITUTIONAL SERVICE LINE 2400 0022SV2 0001
2400 Service Line Revenue Code 0350 2400 Line Item Charge Amount 4711.22 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 1487102027-22 2400 Assigned Number 23
2400 INSTITUTIONAL SERVICE LINE 2400 0023SV2 0001
2400 Service Line Revenue Code 0360 2400 Line Item Charge Amount 7706.07 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 6
ANSI Page: 8
2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-23 2400 Assigned Number 24
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2400 INSTITUTIONAL SERVICE LINE 2400 0026SV2 0001
2400 Service Line Revenue Code 0390 2400 Line Item Charge Amount 576.60 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 372 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-26 2400 Assigned Number 27
2400 INSTITUTIONAL SERVICE LINE 2400 0027SV2 0001
2400 Service Line Revenue Code 0402 2400 Line Item Charge Amount 10068.28 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 1487102027-27 2400 Assigned Number 28
2400 INSTITUTIONAL SERVICE LINE 2400 0028SV2 0001
2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 490134.52 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9999 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-28 2400 Assigned Number 29
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2400 INSTITUTIONAL SERVICE LINE 2400 0030SV2 0001
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2400 INSTITUTIONAL SERVICE LINE 2400 0031SV2 0001
2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 7242.56 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 1487102027-31 2400 Assigned Number 32
ANSI Page: 9
2400 INSTITUTIONAL SERVICE LINE 2400 0032SV2 0001
2400 Service Line Revenue Code 0470 2400 Line Item Charge Amount 5713.49 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 25 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-32 2400 Assigned Number 33
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2400 Service Line Revenue Code 0481 2400 Line Item Charge Amount 5760.51 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 1487102027-33 2400 Assigned Number 34
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2400 Service Line Revenue Code 0483 2400 Line Item Charge Amount 29279.81 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 36 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-34 2400 Assigned Number 35
2400 INSTITUTIONAL SERVICE LINE 2400 0035SV2 0001
2400 Service Line Revenue Code 0610 2400 Line Item Charge Amount 6178.54 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 1487102027-35 2400 Assigned Number 36
2400 INSTITUTIONAL SERVICE LINE 2400 0036SV2 0001
2400 Service Line Revenue Code 0771 2400 Line Item Charge Amount 2293.25 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 1487102027-36 2400 Assigned Number 37
2400 INSTITUTIONAL SERVICE LINE 2400 0037SV2 0001
2400 Service Line Revenue Code 0920 2400 Line Item Charge Amount 15797.47 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 332 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1487102027-37 2400 Assigned Number 38
2400 INSTITUTIONAL SERVICE LINE 2400 0038SV2 0001
2400 Service Line Revenue Code 0921 2400 Line Item Charge Amount 2729.00 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 1487102027-38
ANSI Page: 10
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