Schedule M4 Claims Repricing Retiree FY2025.xlsx

XLSX spreadsheet 606 KB Posted Nov 2, 2026

Attached to: Behavioral Health and Substance Use Disorder Benefits Admin
Solicitation number: RFP 171 260000002410 2
Issued by: Michigan

About this file

Written by GovTribe AI · Nov 3, 2026

This document is a claims repricing worksheet from the State of Michigan for Request for Proposal No. 260000002410 concerning Behavioral Health and Substance Abuse Benefits for the State Health Plan PPO. The file presents historical claims data for retiree members covering the claim paid period of January 1, 2025, through December 31, 2025, organized by place of service across six categories: inpatient hospital services, residential treatment services, day treatment services, outpatient services, intensive outpatient programs, and professional services. The document provides detailed claim information summarized by Tax Identification Number (TIN), Current Procedural Terminology (CPT) codes or revenue codes, and relationship status (employee, spouse, or dependent), with eligible billed charges listed for each combination. Bidders are required to populate the "Allowed Amount" column based on their fee schedule effective January 1, 2028, and designate the appropriate network status code (IC for in-network contracted, OC for out-of-network contracted, IX for in-network non-contracted, or OX for out-of-network non-contracted). Bidders are explicitly instructed not to respond with "IC" status for providers under contract negotiations with unknown outcomes who will be terminating on or after January 1, 2028.

The worksheet contains hundreds of provider records spanning multiple states, with eligible billed charges ranging from nominal amounts to over $180,000 per claim line item. Providers include major Michigan health systems such as Henry Ford Health, Ascension Borgess, Spectrum Health, and Edward W. Sparrow Hospital, as well as out-of-state facilities in Florida, California, Texas, and other states. The document serves as the basis for claims repricing evaluation, enabling bidders to demonstrate their proposed reimbursement rates and network positioning relative to historical claim utilization patterns. No pricing terms, contract amounts, or award information are specified in this worksheet; it functions as a data submission requirement for bid evaluation rather than a pricing or award document.

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Document Cover

STATE OF MICHIGAN

Request For Proposal No. 260000002410

Behavioral Health and Substance Abuse Benefits for the State Health Plan PPO

Schedule F4, Provider Cost & Claims Data Retiree FY2025

Group: Retiree

Claim Paid Period: 01/01/2025 - 12/31/2025

Table of Contents

Tab
1	Definitions

2 Inpatient

3 Residential Treatment

4 Day Treatment

5 Outpatient

6 Intensive Outpatient Program (IOP)

7	Professional Services
Instructions:
Allowed claims paid for each place of service are summarized by TIN, then CPT/Revenue code, and then relationship status. Bidder must provide the Allowed amount in column I and Network Status in column J based the provided eligible claim amounts, provider, CPT/Revenue code information, and Bidder's fee schedule as of 01/01/2028. Definitions for network status can be found on the "Definitions" tab. Bidder must not respond "IC" to any providers that will be terminating on or after 1/1/2028, which are under contract negotiations currently and for which the network status outcome of the contract negotiations is unknown.

Bidder must not alter columns A through J or sort the information

Definitions Definitions:

· Inpatient Hospital Services – Services related only to the hospital or free standing facility charges of an acute inpatient stay.

· Residential Services – Services related only to the Non-hospital or free standing facility charges of a longer term live-in treatment facility.

· Day Treatment Services – Services related only to the delivery of day treatment regardless of setting.

· Outpatient Services – Psychiatric, psychological and substance abuse treatment expenses for providers who have direct contact with a patient. Includes medication management, psychological and substance abuse treatment from qualified providers.

· Intensive Outpatient Program Services – Services provided for 2-3 hours at a time, several days a week in a non-office setting.

· Professional Services – Provider services while the member is inpatient or in residential treatment (higher level of care).

· Eligible Billed Charges – Defined as the amount billed by the provider for benefits eligible for payment under the benefit contract. The Eligible Billed Charges exclude any duplicate claims or disallowed benefits. Claims that are not processed to determine the payment to be made to the provider (e.g. COB claims, bundled/unbundled charges) are excluded from Eligible Billed Charges.

· TIN – Provide the TIN and name of the specific provider rendering the service, even if the physician is part of a larger group practice.

· Network Status - Please use the following codes in the "network status" response field to indicate if the provider is in the network you are proposing as of 01/01/28:

Note - Bidder must not respond "IC" to any providers that will be terminating on or after 1/1/2028, which are under contract negotiations currently and for which the network status outcome of the contract negotiations is unknown.

1. "IC" - In Network Contracted: Use this code for providers with which you have a direct contract and that pay at the in-network level for members

2. "OC" - Out of Network Contracted: Use this code for providers with which you have a secondary contract through a wrap network (or "shared savings" arrangement) and pay at the out-of-network level for members

3. "IX" - In Network Non-Contracted: Use this code for providers with which you do not have a primary or secondary contract, but that pay at the in-network level for members. These types of providers would commonly include "non-member choice" providers such as hospital-based providers including radiologists, pathologists, anesthesiologists, etc. This category might also include ambulatory care and/or dialysis facilities.

4. "OX" - Out of Network Non-Contracted: Use this code for providers which you do not have a primary or secondary contract, and pay at the out-of-network level for members.

5. "OX" - Out of Network Non-Contracted: Use this code for providers which you do not have a primary or secondary contract, and pay at the out-of-network level for members.

· Provider City, State and Zip Code – Provider information should align with place of service and not billing address

· Allowed Amount – Represents the negotiated reimbursement amount for covered services before member cost sharing (e.g., deductible, copayment, or coinsurance). Amount to be populated by bidders which is based on the 01/01/28 fee schedule.

&F&A

Inpatient

Retiree claims paid 01/01/25 - 12/31/25 - Inpatient
Claim information is summarized by Provider, then CPT/Revenue Code, and then Relationship Status (employee / spouse / depdendent). Provider information aligns with place of service and not billing address.
Inpatient Services
TIN	Provider Name	Provider City	Provider State	Provider Zip Code	CPT/Revenue Code	Relationship Status (employee/ spouse/ dependent (child)	Eligible to be Billed	Allowed Amount - Based on 01/01/2028 fee schedule	Network Status

IC, OC, IX, OX

043232990	PHC OF MICHIGAN LLC	NEW BALTIMORE	MI	48047	0124	Subscriber	$21,600.00
208621191	NORTHERN OAK MANAGEMENT COMPANY, LLC	WATERFORD	MI	48328	0022	Spouse	$0.00
208621191	NORTHERN OAK MANAGEMENT COMPANY, LLC	WATERFORD	MI	48328	0191	Spouse	$7,800.00
208621191	NORTHERN OAK MANAGEMENT COMPANY, LLC	WATERFORD	MI	48328	0250	Spouse	$71.56
208621191	NORTHERN OAK MANAGEMENT COMPANY, LLC	WATERFORD	MI	48328	0420	Spouse	$3,700.00
208621191	NORTHERN OAK MANAGEMENT COMPANY, LLC	WATERFORD	MI	48328	0430	Spouse	$3,600.00
232285657	FOREST VIEW PSYCHIATRIC HOSPITAL INC	GRAND RAPIDS	MI	49546	0124	Dependent	$81,000.00
232285657	FOREST VIEW PSYCHIATRIC HOSPITAL INC	GRAND RAPIDS	MI	49546	0124	Spouse	$25,200.00
232285657	FOREST VIEW PSYCHIATRIC HOSPITAL INC	GRAND RAPIDS	MI	49546	0250	Dependent	$8,016.72
232285657	FOREST VIEW PSYCHIATRIC HOSPITAL INC	GRAND RAPIDS	MI	49546	0300	Dependent	$101.55
232922437	WINDMOOR HEALTHCARE INC	CLEARWATER	FL	33764	0124	Subscriber	$6,600.00
232922437	WINDMOOR HEALTHCARE INC	CLEARWATER	FL	33764	0250	Subscriber	$3,940.15
263333652	BCA OF DETROIT, LLC	DETROIT	MI	48205	0124	Subscriber	$32,400.00
263333652	BCA OF DETROIT, LLC	DETROIT	MI	48205	0250	Subscriber	$2,737.85
263333652	BCA OF DETROIT, LLC	DETROIT	MI	48205	0301	Subscriber	$33.00
352565165	WOODLAND SPRINGS, LLC	CONROE	TX	77384	0124	Dependent	$14,604.40
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0120	Spouse	$5,607.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0200	Spouse	$22,270.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0250	Spouse	$3,725.50
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0260	Spouse	$1,744.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0271	Spouse	$1,571.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0272	Spouse	$1,527.25
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0300	Spouse	$442.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0301	Spouse	$6,421.75
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0305	Spouse	$661.50
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0306	Spouse	$402.25
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0307	Spouse	$53.50
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0324	Spouse	$451.50
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0351	Spouse	$1,346.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0352	Spouse	$8,493.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0361	Spouse	$914.25
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0410	Spouse	$4,242.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0441	Spouse	$554.50
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0444	Spouse	$346.50
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0450	Spouse	$4,572.00
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0460	Spouse	$4,833.50
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0483	Spouse	$2,312.75
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0636	Spouse	$4,897.75
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0730	Spouse	$257.25
380593405	METROPOLITAN HOSPITAL	WYOMING	MI	49519	0920	Spouse	$410.25
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0114	Dependent	$7,985.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0114	Subscriber	$51,104.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0250	Dependent	$196.38
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0250	Subscriber	$10,605.97
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0258	Dependent	$342.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0258	Subscriber	$1,026.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0270	Subscriber	$25.20
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0272	Subscriber	$637.12
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0301	Dependent	$862.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0301	Subscriber	$60.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0305	Dependent	$48.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0306	Subscriber	$450.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0307	Dependent	$115.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0370	Subscriber	$7,037.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0450	Dependent	$3,132.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0710	Subscriber	$10,324.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0730	Dependent	$464.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0730	Subscriber	$232.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0780	Dependent	$93.00
380833014	MYMICHIGAN MEDICAL CENTER MIDLAND	MIDLAND	MI	48670	0901	Subscriber	$14,688.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0120	Subscriber	$12,414.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0250	Subscriber	$2,894.08
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0258	Subscriber	$456.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0301	Subscriber	$2,626.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0302	Subscriber	$66.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0305	Subscriber	$358.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0309	Subscriber	$29.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0320	Subscriber	$176.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0324	Subscriber	$152.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0410	Subscriber	$1,464.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0421	Subscriber	$251.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0424	Subscriber	$402.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0431	Subscriber	$177.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0434	Subscriber	$292.00
380997730	MYMICHIGAN MEDICAL CENTER SAGINAW	SAGINAW	MI	48601	0730	Subscriber	$191.00
381357020	HENRY FORD HEALTH SYSTEM	WEST BLOOMFIELD	MI	48322	0124	Dependent	$14,315.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0120	Spouse	$8,010.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0126	Spouse	$3,984.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0250	Spouse	$242.97
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0301	Spouse	$839.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0302	Spouse	$160.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0305	Spouse	$49.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0306	Spouse	$66.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0900	Spouse	$351.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0914	Spouse	$336.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0915	Spouse	$2,120.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0960	Spouse	$695.00
381357020	HENRY FORD MAPLEGROVE CENTER	WEST BLOOMFIELD	MI	48322	0988	Spouse	$842.00
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0124	Dependent	$7,260.75
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0124	Subscriber	$9,681.00
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0250	Dependent	$82.74
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0250	Subscriber	$373.80
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0300	Dependent	$2,317.75
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0300	Subscriber	$2,124.75
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0301	Dependent	$607.00
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0301	Subscriber	$318.25
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0305	Dependent	$210.00
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0307	Dependent	$163.25
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0450	Dependent	$2,530.75
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0730	Dependent	$294.75
381358208	MEMORIAL HOSPITAL	OWOSSO	MI	48867	0942	Dependent	$49.75
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0124	Spouse	$55,258.00
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0250	Spouse	$1,346.25
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0260	Spouse	$700.00
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0301	Spouse	$903.00
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0305	Spouse	$151.00
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0306	Spouse	$299.00
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0307	Spouse	$15.00
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0320	Spouse	$208.00
381358212	HENRY FORD HEALTH PROVIDENCE HOSPITAL	SOUTHFIELD	MI	48075	0450	Spouse	$3,266.00
381358410	LUTHERAN HOMES OF MICHIGAN, INC.	FRANKENMUTH	MI	48734	0440	Subscriber	$100.00
381358410	LUTHERAN HOMES OF MICHIGAN, INC.	FRANKENMUTH	MI	48734	0444	Subscriber	$100.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0121	Subscriber	$2,324.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0206	Subscriber	$4,026.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0250	Subscriber	$85.50
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0260	Subscriber	$279.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0300	Subscriber	$30.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0301	Subscriber	$385.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0302	Subscriber	$76.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0305	Subscriber	$127.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0307	Subscriber	$46.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0320	Subscriber	$271.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0351	Subscriber	$1,153.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0352	Subscriber	$968.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0421	Subscriber	$278.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0424	Subscriber	$309.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0431	Subscriber	$120.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0434	Subscriber	$296.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0450	Subscriber	$2,860.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0483	Subscriber	$3,797.00
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0636	Subscriber	$194.50
381359063	HENRY FORD HEALTH ST. JOHN HOSPITAL	CHICAGO	IL	60677	0730	Subscriber	$72.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0120	Spouse	$9,705.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0250	Spouse	$1,388.10
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0255	Spouse	$165.90
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0260	Spouse	$1,522.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0301	Spouse	$1,762.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0305	Spouse	$359.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0320	Spouse	$498.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0351	Spouse	$2,902.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0352	Spouse	$3,354.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0410	Spouse	$2,373.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0421	Spouse	$537.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0424	Spouse	$497.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0431	Spouse	$766.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0434	Spouse	$534.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0450	Spouse	$3,195.00
381360526	ASCENSION BORGESS HOSPITAL	KALAMAZOO	MI	49048	0483	Spouse	$1,963.00
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0121	Spouse	$5,906.00
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0250	Spouse	$2,157.58
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0260	Spouse	$8,928.00
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0300	Spouse	$127.38
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0301	Spouse	$1,633.98
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0305	Spouse	$240.48
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0307	Spouse	$19.02
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0450	Spouse	$2,140.00
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0730	Spouse	$204.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0114	Spouse	$15,156.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0124	Dependent	$124,572.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0124	Subscriber	$14,830.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0134	Dependent	$22,944.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0134	Subscriber	$2,868.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0250	Dependent	$3,315.34
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0250	Spouse	$1,142.16
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0250	Subscriber	$776.05
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0300	Dependent	$788.82
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0300	Spouse	$127.38
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0300	Subscriber	$163.32
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0301	Dependent	$3,493.84
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0301	Spouse	$634.20
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0301	Subscriber	$707.14
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0305	Dependent	$279.72
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0305	Subscriber	$46.62
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0306	Dependent	$2,875.20
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0306	Subscriber	$855.78
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0450	Dependent	$9,132.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0450	Subscriber	$2,140.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0730	Dependent	$612.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0730	Subscriber	$816.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0914	Dependent	$2,769.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0914	Spouse	$820.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0914	Subscriber	$1,293.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0915	Dependent	$16,032.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0915	Spouse	$2,933.00
381360584	EDWARD W. SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0915	Subscriber	$1,829.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0124	Spouse	$7,338.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0250	Spouse	$605.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0258	Spouse	$82.15
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0300	Spouse	$50.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0301	Spouse	$2,027.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0306	Spouse	$118.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0450	Spouse	$3,433.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0730	Spouse	$552.00
381362830	MUNSON MEDICAL CENTER	TRAVERSE CITY	MI	49684	0942	Spouse	$74.00
381368347	ELLA E. M. BROWN CHARITABLE CIRCLE	MARSHALL	MI	49068	0124	Dependent	$35,235.00
381368347	ELLA E. M. BROWN CHARITABLE CIRCLE	MARSHALL	MI	49068	0250	Dependent	$146.26
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0114	Dependent	$49,000.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0114	Spouse	$41,650.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0114	Subscriber	$24,500.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0124	Dependent	$29,400.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0124	Spouse	$22,050.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0126	Subscriber	$4,650.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0250	Dependent	$1,252.15
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0250	Spouse	$7,473.76
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0250	Subscriber	$648.22
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0300	Dependent	$172.76
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0301	Dependent	$1,799.63
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0301	Spouse	$616.51
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0301	Subscriber	$334.31
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0302	Dependent	$27.54
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0305	Dependent	$52.95
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0305	Spouse	$35.30
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0305	Subscriber	$50.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0306	Dependent	$419.71
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0730	Subscriber	$71.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0900	Dependent	$7,200.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0915	Subscriber	$426.00
381369611	MCLAREN PORT HURON	PORT HURON	MI	48060	0124	Subscriber	$11,730.00
381369611	MCLAREN PORT HURON	PORT HURON	MI	48060	0250	Subscriber	$786.17
381369611	MCLAREN PORT HURON	PORT HURON	MI	48060	0301	Subscriber	$375.20
381369611	MCLAREN PORT HURON	PORT HURON	MI	48060	0637	Subscriber	$522.20
381369611	MCLAREN PORT HURON	PORT HURON	MI	48060	0730	Subscriber	$113.00
381437919	MYMICHIGAN MEDICAL CENTER ALMA	ALMA	MI	48801	0114	Subscriber	$13,288.00
381437919	MYMICHIGAN MEDICAL CENTER ALMA	ALMA	MI	48801	0250	Subscriber	$144.10
381576680	HENRY FORD HEALTH BRIGHTON CENTER FOR RECOVERY	BRIGHTON	MI	48116	0120	Spouse	$15,120.00
381576680	HENRY FORD HEALTH BRIGHTON CENTER FOR RECOVERY	BRIGHTON	MI	48116	0126	Spouse	$2,300.00
381576680	HENRY FORD HEALTH BRIGHTON CENTER FOR RECOVERY	BRIGHTON	MI	48116	0914	Spouse	$250.00
381576680	HENRY FORD HEALTH BRIGHTON CENTER FOR RECOVERY	BRIGHTON	MI	48116	0915	Spouse	$1,300.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0124	Dependent	$12,130.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0124	Subscriber	$12,130.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0250	Dependent	$241.84
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0250	Subscriber	$356.23
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0260	Subscriber	$302.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0301	Dependent	$780.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0301	Subscriber	$818.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0305	Dependent	$59.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0305	Subscriber	$59.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0306	Subscriber	$262.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0307	Subscriber	$50.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0450	Dependent	$1,731.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0450	Subscriber	$2,639.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0730	Dependent	$222.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL	JACKSON	MI	49201	0730	Subscriber	$222.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0120	Dependent	$22,295.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0120	Subscriber	$15,435.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0250	Dependent	$310.37
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0250	Subscriber	$663.36
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0301	Dependent	$661.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0301	Subscriber	$71.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0302	Subscriber	$76.00
382027689	W.A. FOOTE MEMORIAL HOSPITAL, INC.	JACKSON	MI	49201	0305	Dependent	$56.00
382146751	MCLAREN NORTHERN MICHIGAN	CHEBOYGAN	MI	49721	0124	Spouse	$15,104.00
382146751	MCLAREN NORTHERN MICHIGAN	CHEBOYGAN	MI	49721	0250	Spouse	$592.56
382146751	MCLAREN NORTHERN MICHIGAN	CHEBOYGAN	MI	49721	0301	Spouse	$1,018.20
382146751	MCLAREN NORTHERN MICHIGAN	CHEBOYGAN	MI	49721	0305	Spouse	$122.70
382146751	MCLAREN NORTHERN MICHIGAN	CHEBOYGAN	MI	49721	0307	Spouse	$54.90
382146751	MCLAREN NORTHERN MICHIGAN	CHEBOYGAN	MI	49721	0450	Spouse	$1,715.00
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0124	Subscriber	$11,270.00
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0250	Subscriber	$724.72
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0300	Subscriber	$62.10
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0301	Subscriber	$841.00
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0307	Subscriber	$34.00
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0421	Subscriber	$145.00
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0424	Subscriber	$314.00
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0450	Subscriber	$1,579.00
382156872	LAKELAND HOSPITALS AT NILES AND ST JOSEPH, INC	SAINT JOSEPH	MI	49085	0762	Subscriber	$1,224.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0120	Dependent	$11,200.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0120	Subscriber	$7,000.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0126	Subscriber	$2,100.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0250	Dependent	$240.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0250	Subscriber	$220.50
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0300	Dependent	$56.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0300	Subscriber	$56.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0914	Dependent	$855.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0915	Dependent	$6,256.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0915	Subscriber	$272.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0919	Dependent	$570.00
382233166	COMMUNITY PROGRAMS INC.	WATERFORD	MI	48327	0919	Subscriber	$570.00
382383119	MCLAREN FLINT	FLINT	MI	48532	0124	Dependent	$18,102.00
382383119	MCLAREN FLINT	FLINT	MI	48532	0250	Dependent	$69.37
382409580	HAVENWYCK HOSPITAL INC	AUBURN HILLS	MI	48326	0134	Dependent	$25,500.00
382409580	HAVENWYCK HOSPITAL INC	AUBURN HILLS	MI	48326	0134	Subscriber	$28,500.00
382409580	HAVENWYCK HOSPITAL INC	AUBURN HILLS	MI	48326	0250	Dependent	$747.57
382409580	HAVENWYCK HOSPITAL INC	AUBURN HILLS	MI	48326	0250	Subscriber	$961.53
382409580	HAVENWYCK HOSPITAL INC	AUBURN HILLS	MI	48326	0300	Dependent	$232.44
382409580	HAVENWYCK HOSPITAL INC	AUBURN HILLS	MI	48326	0300	Subscriber	$154.17
382409580	HAVENWYCK HOSPITAL INC	ST JOHNS	MI	48879	0124	Dependent	$116,000.00
382409580	HAVENWYCK HOSPITAL INC	ST JOHNS	MI	48879	0124	Subscriber	$68,000.00
382409580	HAVENWYCK HOSPITAL INC	ST JOHNS	MI	48879	0250	Dependent	$5,402.58
382409580	HAVENWYCK HOSPITAL INC	ST JOHNS	MI	48879	0250	Subscriber	$4,026.90
382409580	HAVENWYCK HOSPITAL INC	ST JOHNS	MI	48879	0300	Dependent	$237.60
382409580	HAVENWYCK HOSPITAL INC	ST JOHNS	MI	48879	0300	Subscriber	$48.45
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0124	Spouse	$36,970.00
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0250	Spouse	$175.70
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0301	Spouse	$1,023.00
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0302	Spouse	$69.00
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0305	Spouse	$102.00
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0307	Spouse	$42.00
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0450	Spouse	$1,330.00
382589966	MERCY HEALTH PARTNERS	MUSKEGON	MI	49442	0730	Spouse	$153.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0124	Dependent	$22,934.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0124	Subscriber	$54,298.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0250	Dependent	$388.62
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0250	Subscriber	$1,629.17
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0301	Dependent	$386.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0301	Subscriber	$923.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0305	Subscriber	$96.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0730	Subscriber	$514.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0780	Dependent	$98.00
382602147	MYMICHIGAN MEDICAL CENTER SAULT	KINCHELOE	MI	49788	0780	Subscriber	$188.00
383175878	ST JOSEPH MERCY HOSPITAL	YPSILANTI	MI	48197	0114	Spouse	$41,235.00
383175878	ST JOSEPH MERCY HOSPITAL	YPSILANTI	MI	48197	0250	Spouse	$468.65
383175878	ST JOSEPH MERCY HOSPITAL	YPSILANTI	MI	48197	0301	Spouse	$470.00
383175878	ST JOSEPH MERCY HOSPITAL	YPSILANTI	MI	48197	0320	Spouse	$943.00
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0120	Subscriber	$2,958.00
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0250	Subscriber	$1,942.88
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0260	Subscriber	$1,513.00
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0301	Subscriber	$1,198.00
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0305	Subscriber	$159.00
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0352	Subscriber	$3,024.00
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0450	Subscriber	$1,854.00
383218134	SPARROW IONIA HOSPITAL	IONIA	MI	48846	0730	Subscriber	$128.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0120	Subscriber	$10,438.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0250	Subscriber	$1,783.25
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0258	Subscriber	$378.91
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0300	Subscriber	$186.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0301	Subscriber	$5,177.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0305	Subscriber	$749.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0351	Subscriber	$5,091.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0359	Subscriber	$451.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0421	Subscriber	$184.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0424	Subscriber	$207.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0431	Subscriber	$184.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0434	Subscriber	$207.00
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0636	Subscriber	$759.53
383330803	TRINITY HEALTH GRAND HAVEN HOSPITAL	GRAND HAVEN	MI	49417	0730	Subscriber	$167.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0120	Dependent	$3,398.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0206	Dependent	$47,166.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0250	Dependent	$4,256.32
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0260	Dependent	$3,061.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0270	Dependent	$210.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0272	Dependent	$304.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0300	Dependent	$1,777.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0301	Dependent	$3,781.70
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0305	Dependent	$432.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0307	Dependent	$50.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0320	Dependent	$211.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0351	Dependent	$2,075.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0370	Dependent	$795.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0450	Dependent	$1,380.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0460	Dependent	$4,760.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0480	Dependent	$2,347.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0611	Dependent	$3,836.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0636	Dependent	$400.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0730	Dependent	$780.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0740	Dependent	$2,660.00
383369438	COVENANT MEDICAL CENTER, INC.	SAGINAW	MI	48602	0762	Dependent	$2,142.00
384149930	SANFORD WEST LLC	MARNE	MI	49435	0120	Subscriber	$55,000.00
386004889	HEALTHSOURCE SAGINAW INC	SAGINAW	MI	48603	0124	Dependent	$14,756.00
386004889	HEALTHSOURCE SAGINAW INC	SAGINAW	MI	48603	0250	Dependent	$194.84
386004889	HEALTHSOURCE SAGINAW INC	SAGINAW	MI	48603	0301	Dependent	$39.00
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0124	Subscriber	$15,157.50
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0250	Subscriber	$576.04
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0300	Subscriber	$95.50
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0301	Subscriber	$1,042.50
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0302	Subscriber	$215.50
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0305	Subscriber	$46.50
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0307	Subscriber	$18.00
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0351	Subscriber	$2,884.50
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0450	Subscriber	$2,615.00
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0611	Subscriber	$3,448.50
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0730	Subscriber	$226.00
386005601	HURLEY MEDICAL CENTER	FLINT	MI	48503	0940	Subscriber	$651.50
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0124	Subscriber	$34,174.00
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0250	Subscriber	$1,814.81
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0300	Subscriber	$1,269.00
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0410	Subscriber	$3,843.00
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0431	Subscriber	$600.00
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0434	Subscriber	$393.00
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0450	Subscriber	$3,300.00
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0730	Subscriber	$181.00
386006309	REGENTS OF THE UNIVERSITY OF MICHIGAN	ANN ARBOR	MI	48109	0762	Subscriber	$925.68
474120830	LAGUNA TREATMENT HOSPITAL, LLC	ALISO VIEJO	CA	92656	0126	Subscriber	$60,000.00
474195292	YARROW LODGE, LLC	AUGUSTA	MI	49012	0120	Subscriber	$119,412.00
474195292	YARROW LODGE, LLC	AUGUSTA	MI	49012	0126	Subscriber	$24,750.00
581791069	LA AMISTAD RESIDENTIAL TREATMENT CENTER LLC	ORLANDO	FL	32821	0124	Subscriber	$4,400.00
581791069	LA AMISTAD RESIDENTIAL TREATMENT CENTER LLC	ORLANDO	FL	32821	0250	Subscriber	$235.01
581791069	LA AMISTAD RESIDENTIAL TREATMENT CENTER LLC	ORLANDO	FL	32821	0300	Subscriber	$48.00
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0121	Subscriber	$10,458.15
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0206	Subscriber	$25,214.30
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0250	Subscriber	$999.16
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0255	Subscriber	$119.60
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0259	Subscriber	$17,238.63
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0300	Subscriber	$2,732.37
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0301	Subscriber	$37,610.96
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0305	Subscriber	$10,271.23
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0306	Subscriber	$3,823.28
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0307	Subscriber	$974.76
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0320	Subscriber	$5,719.44
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0324	Subscriber	$2,597.94
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0351	Subscriber	$7,113.12
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0352	Subscriber	$9,984.31
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0450	Subscriber	$27,126.94
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0460	Subscriber	$361.55
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0636	Subscriber	$7,672.82
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0730	Subscriber	$2,988.20
592108057	FLORIDA HOSPITAL ZEPHYRHILLS INC	ZEPHYRHILLS	FL	33541	0762	Subscriber	$8,163.36
596012500	SARASOTA COUNTY PUBLIC HOSPITAL DISTRICT	SARASOTA	FL	34239	0124	Subscriber	$22,836.00
596012500	SARASOTA COUNTY PUBLIC HOSPITAL DISTRICT	SARASOTA	FL	34239	0250	Subscriber	$277.25
596012500	SARASOTA COUNTY PUBLIC HOSPITAL DISTRICT	SARASOTA	FL	34239	0300	Subscriber	$33.81
596012500	SARASOTA COUNTY PUBLIC HOSPITAL DISTRICT	SARASOTA	FL	34239	0301	Subscriber	$603.00
596012500	SARASOTA COUNTY PUBLIC HOSPITAL DISTRICT	SARASOTA	FL	34239	0305	Subscriber	$108.00
611744825	ELITE CARE, INC.	COSTA MESA	CA	92626	0156	Subscriber	$37,560.00
611744825	ELITE CARE, INC.	COSTA MESA	CA	92626	0158	Subscriber	$184,275.00
621864266	TEXAS CYPRESS CREEK HOSPITAL LP	HOUSTON	TX	77090	0124	Dependent	$16,000.00
621864266	TEXAS CYPRESS CREEK HOSPITAL LP	HOUSTON	TX	77090	0250	Dependent	$1,109.58
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0110	Subscriber	$7,202.25
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0114	Subscriber	$34,669.50
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0250	Subscriber	$2,926.24
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0300	Subscriber	$844.13
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0301	Subscriber	$5,930.64
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0305	Subscriber	$522.30
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0307	Subscriber	$92.64
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0320	Subscriber	$1,282.79
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0350	Subscriber	$3,565.30
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0351	Subscriber	$8,216.24
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0352	Subscriber	$8,742.26
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0420	Subscriber	$528.09
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0424	Subscriber	$371.93
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0430	Subscriber	$173.08
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0434	Subscriber	$371.93
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0450	Subscriber	$11,176.47
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0637	Subscriber	$1,285.80
800818718	DLP MARQUETTE GENERAL HOSPITAL LLC	MARQUETTE	MI	49855	0730	Subscriber	$766.90
822335258	GAYLORD OPCO, LLC	GAYLORD	MI	49735	0300	Spouse	$50.00
822335258	GAYLORD OPCO, LLC	GAYLORD	MI	49735	0430	Spouse	$68.00
822335258	GAYLORD OPCO, LLC	GAYLORD	MI	49735	0434	Spouse	$181.00
822335258	GAYLORD OPCO, LLC	GAYLORD	MI	49735	0440	Spouse	$4,443.00
822335258	GAYLORD OPCO, LLC	GAYLORD	MI	49735	0444	Spouse	$390.00
831978365	MICHIGAN BH JV, LLC	DEARBORN	MI	48124	0124	Spouse	$16,000.00
831978365	MICHIGAN BH JV, LLC	DEARBORN	MI	48124	0124	Subscriber	$60,000.00
831978365	MICHIGAN BH JV, LLC	DEARBORN	MI	48124	0250	Subscriber	$13,994.40
831978365	MICHIGAN BH JV, LLC	DEARBORN	MI	48124	0300	Subscriber	$3.00
832064722	REMEDY THERAPY, LLC	STUART	FL	34997	0126	Subscriber	$49,500.00
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0110	Spouse	$4,512.08
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0250	Spouse	$4,108.35
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0258	Spouse	$350.00
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0272	Spouse	$4,824.54
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0300	Spouse	$34.67
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0301	Spouse	$964.86
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0305	Spouse	$300.00
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0312	Spouse	$708.00
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0360	Spouse	$22,560.00
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0370	Spouse	$3,121.17
843683956	SANA HEALTHCARE CARROLLTON	CARROLLTON	TX	75010	0710	Spouse	$1,543.50
862362291	BRONSON-ACADIA JOINT VENTURE, LLC	BATTLE CREEK	MI	49015	0124	Dependent	$20,000.00
862362291	BRONSON-ACADIA JOINT VENTURE, LLC	BATTLE CREEK	MI	49015	0124	Spouse	$50,000.00
862362291	BRONSON-ACADIA JOINT VENTURE, LLC	BATTLE CREEK	MI	49015	0124	Subscriber	$60,000.00
862362291	BRONSON-ACADIA JOINT VENTURE, LLC	BATTLE CREEK	MI	49015	0250	Spouse	$168.09
862362291	BRONSON-ACADIA JOINT VENTURE, LLC	BATTLE CREEK	MI	49015	0250	Subscriber	$677.36
862362291	BRONSON-ACADIA JOINT VENTURE, LLC	BATTLE CREEK	MI	49015	0301	Spouse	$6.00
862362291	BRONSON-ACADIA JOINT VENTURE, LLC	BATTLE CREEK	MI	49015	0301	Subscriber	$6.00
871785438	KALAMAZOO TC OPERATOR LLC	KALAMAZOO	MI	49006	0944	Subscriber	$1,448.70
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0124	Dependent	$42,000.00
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0124	Spouse	$16,800.00
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0124	Subscriber	$18,900.00
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0250	Dependent	$855.94
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0250	Spouse	$187.30
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0250	Subscriber	$682.76
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0301	Dependent	$10.00
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0306	Dependent	$129.00
872121325	HFHS-ACADIA JOINT VENTURE, LLC	WEST BLOOMFIELD	MI	48322	0307	Dependent	$3.00
882846756	WE BOW DOWN	PALOS VERDES ESTATES	CA	90274	0156	Subscriber	$68,000.00
884117564	MESA DEVELOPMENT SUB, LLC	MESA	AZ	85212	0124	Dependent	$8,100.00
884117564	MESA DEVELOPMENT SUB, LLC	MESA	AZ	85212	0250	Dependent	$120.99
884117564	MESA DEVELOPMENT SUB, LLC	MESA	AZ	85212	0301	Dependent	$440.00
884117564	MESA DEVELOPMENT SUB, LLC	MESA	AZ	85212	0302	Dependent	$7.00

Residential Treatment

Retiree claims paid 01/01/25 - 12/31/25 - Residential Treatment
Claim information is summarized by Provider, then CPT/Revenue Code, and then Relationship Status (employee / spouse / depdendent). Provider information aligns with place of service and not billing address.
Residential Services
TIN	Provider Name	Provider City	Provider State	Provider Zip Code	CPT/Revenue Code	Relationship Status (employee/ spouse/ dependent (child)	Eligible to be Billed	Allowed Amount - Based on 01/01/2028 fee schedule	Network Status

IC, OC, IX, OX

384149930	SANFORD WEST LLC	MARNE	MI	49435	0126	Spouse	$9,000.00
461912262	BLACK BEAR TREATMENT CENTER LLC	SAUTEE	GA	30571	1002	Subscriber	$38,520.00
463424864	SUNSPIRE HEALTH FLORIDA, LLC	TAMPA	FL	33606	0126	Subscriber	$30,975.00
463424864	SUNSPIRE HEALTH FLORIDA, LLC	TAMPA	FL	33606	1002	Subscriber	$115,855.00
471156415	JOURNEYPURE PANHANDLE LLC	PANAMA CITY BEACH	FL	32413	1002	Dependent	$94,975.00
474120830	LAGUNA TREATMENT HOSPITAL, LLC	ALISO VIEJO	CA	92656	1002	Subscriber	$33,250.00
593730600	RENAISSANCE HEALTHCARE GROUP	SEVIERVILLE	TN	37862	1001	Dependent	$65,650.00
650101421	CENTER FOR ALCOHOL AND DRUG STUDIES, LLC.	LAKE WORTH	FL	33467	1002	Subscriber	$130,330.80
832064722	REMEDY THERAPY, LLC	STUART	FL	34997	1002	Subscriber	$48,000.00
843685045	CARDINAL RECOVERY LLC	SOUTH BEND	IN	46615	0126	Subscriber	$943.25
871331752	WASHINGTON YA SERVICES LLC	SNOHOMISH	WA	98296	1001	Dependent	$146,850.00
871785438	KALAMAZOO TC OPERATOR LLC	KALAMAZOO	MI	49006	0120	Subscriber	$10,670.66
871785438	KALAMAZOO TC OPERATOR LLC	KALAMAZOO	MI	49006	0126	Subscriber	$32,700.00
882846756	WE BOW DOWN	PALOS VERDES ESTATES	CA	90274	1002	Subscriber	$33,200.00
900485646	LA JOLLA RECOVERY INC	SAN DIEGO	CA	92109	1002	Subscriber	$17,250.00
933860252	PASADENA VILLA MICHIGAN, LLC	BATTLE CREEK	MI	49017	1001	Dependent	$50,500.00

Day Treatment

Retiree claims paid 01/01/25 - 12/31/25 - Day Treatment
Claim information is summarized by Provider, then CPT/Revenue Code, and then Relationship Status (employee / spouse / depdendent). Provider information aligns with place of service and not billing address.
Day Treatment Services
TIN	Provider Name	Provider City	Provider State	Provider Zip Code	CPT/Revenue Code	Relationship Status (employee/ spouse/ dependent (child)	Eligible to be Billed	Allowed Amount - Based on 01/01/2028 fee schedule	Network Status

IC, OC, IX, OX

028780733	PARTHA, RISHI	GRAND RAPIDS	MI	49548	99232	Spouse	$189.00
028780733	PARTHA, RISHI	GRAND RAPIDS	MI	49548	99239	Spouse	$269.00
232285657	FOREST VIEW PSYCHIATRIC HOSPITAL INC	GRAND RAPIDS	MI	49546	0912	Dependent	$2,700.00
232285657	FOREST VIEW PSYCHIATRIC HOSPITAL INC	GRAND RAPIDS	MI	49546	0912	Spouse	$11,700.00
351660893	SCHELLENBERG, DANIEL	GRAND RAPIDS	MI	49548	99221	Dependent	$130.00
351660893	SCHELLENBERG, DANIEL	GRAND RAPIDS	MI	49548	99232	Dependent	$260.00
364723886	MATHIS-ALLEN, VALERIE	GRAND RAPIDS	MI	49548	99223	Spouse	$418.00
364827394	MOUSA, FAHD	CHARLESTON	WV	25304	99221	Spouse	$130.00
364827394	QUADRI, SYEDA	WICHITA	KS	67214	99222	Spouse	$190.00
364827394	QUADRI, SYEDA	WICHITA	KS	67214	99231	Spouse	$400.00
364827394	QUADRI, SYEDA	WICHITA	KS	67214	99232	Spouse	$730.00
368728295	WASSEF, SAMY	JACKSON	MI	49201	99223	Subscriber	$640.00
381360584	EDWARD W SPARROW HOSPITAL ASSOCIATION	LANSING	MI	48912	0901	Subscriber	$1,285.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0912	Dependent	$19,935.00
381368360	PINE REST CHRISTIAN MENTAL HEALTH SERVICES	GRAND RAPIDS	MI	49548	0912	Spouse	$6,360.40
381976271	COX, RYAN	SAGINAW	MI	48602	90792	Dependent	$339.00
382027689	ALLAN, SUSAN	JACKSON	MI	49202	90791	Subscriber	$351.00
382800065	HOLLAND COMMUNITY HOSPITAL	HOLLAND	MI	49423	0912	Spouse	$12,060.00
383006825	ISMAIL B. SENDI, MD, PC	CLARKSTON	MI	48346	S0201	Dependent	$46,900.00
383006825	ISMAIL B. SENDI, MD, PC	CLARKSTON	MI	48346	S0201	Subscriber	$22,200.00
383111271	KLOHA, HANNAH	MIDLAND	MI	48640	99232	Dependent	$220.00
384904042	NICHOLAS, ADAM	AUBURN	MI	48611	99238	Dependent	$151.00
391139101	ROGERS MEMORIAL HOSPITAL INCORPORATED	OCONOMOWOC	WI	53066	0912	Dependent	$15,470.00
463424864	SUNSPIRE HEALTH FLORIDA, LLC	TAMPA	FL	33606	0912	Subscriber	$49,425.00
465723097	WESTSIDE TREATMENT, LLC.	LOS ANGELES	CA	90064	0913	Subscriber	$13,500.00
472449231	A BETTER LIFE RECOVERY LLC	SAN JUAN CAPISTRANO	CA	92675	0913	Subscriber	$65,000.00
474195292	YARROW LODGE, LLC	AUGUSTA	MI	49012	0912	Subscriber	$75,504.00
611744825	ELITE CARE, INC.	NEWPORT BEACH	CA	92660	0913	Subscriber	$28,755.00
824700551	DAMATO, MICHAEL	BRADENTON	FL	34208	90870	Subscriber	$337.00
831978365	MICHIGAN BH JV, LLC	DEARBORN	MI	48124	0913	Spouse	$1,000.00
863830786	HORETSKI, JOSEPH	AUBURN	MI	48611	99232	Dependent	$550.00
863830786	HORETSKI, JOSEPH	AUBURN	MI	48611	99233	Dependent	$948.78
933860252	PASADENA VILLA MICHIGAN, LLC	LANSING	MI	48917	S0201	Subscriber	$43,000.00

Outpatient

Retiree claims paid 01/01/25 - 12/31/25 - Outpatient
Claim information is summarized by Provider, then CPT/Revenue Code, and then Relationship Status (employee / spouse / depdendent). Provider information aligns with place of service and not billing address.
Outpatient Services
TIN	Provider Name	Provider City	Provider State	Provider Zip Code	CPT/Revenue Code	Relationship Status (employee/ spouse/ dependent (child)	Eligible to be Billed	Allowed Amount - Based on 01/01/2028 fee schedule	Network Status

IC, OC, IX, OX

208488713	PASCO-PINELLAS HILLSBOROUGH COMMUNITY HEALTH SYSTEM INC	WESLEY CHAPEL	FL	33544	0259	Subscriber	$54.32
208488713	PASCO-PINELLAS HILLSBOROUGH COMMUNITY HEALTH SYSTEM INC	WESLEY CHAPEL	FL	33544	0301	Subscriber	$3,351.90
208488713	PASCO-PINELLAS HILLSBOROUGH COMMUNITY HEALTH SYSTEM INC	WESLEY CHAPEL	FL	33544	0305	Subscriber	$442.59

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Nov 3, 2026.